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Research shows perineal massage in the third trimester is likely to reduce your chances of perineal trauma (Abdelhakim et al, 2020). What's more, most mums-to-be who tried perineal massage felt comfortable and positive about their experience. They said they'd do it again in another pregnancy and would recommend it to others (Labrecque et al, 2001).

The perineum is the skin and muscle between vagina and anus. You can massage your perineum by yourself, or with your partner if you'd prefer.

Perineal massage aims to stretch, usually using two fingers, the perineal tissues ready for birth.

You can start practising perineal massage whenever you like, and many women will start during the third trimester. Avoid perineal massage if you have vaginal herpes, thrush or a vaginal infection (Oxford University NHS Trust, 2014). Here's what you'll need:

Clean hands and short nails to protect the delicate tissues in your vagina and perineum (RCOG, no date).

Unscented lubricant or oils - eg. vitamin E oil, almond or olive (RCOG, no date). Unscented personal lubricant would be fine.

One or two pillows might be handy for your comfort - if you'd prefer to sit or lie back. Some people find it pleasant to relax in a bath first. Other people prefer to do the massage standing.

Some people find it helps to use a mirror so they can see what they're doing.

1. Be prepared

Wash your hands thoroughly and make sure your or your partner's (if they're helping) fingernails are short.

Find somewhere you can relax, uninterrupted and in privacy with your legs open wide and your knees bent.

Make sure you have your chosen oil and your mirror handy if you need it.

2. Find a comfy position for you

You could try:

being propped up with pillows on a bed or sofa so you or your partner can reach your perineum more easily

reclining in the bath with one leg up on the side at a time

standing in a warm shower with one leg up on a stool before you change legs

sitting on the toilet.

3. Lubricate your perineum

Put some oil on your perineum and the lower part of your vaginal opening. This helps to make the massage more comfortable.

4. Relax and start the massage

Taking some deep breaths might help you relax.

1. Put your thumbs about 2.5cm to 4cm just inside the back wall of your vagina. You might find it easier to use a mirror the first few times.

2. Press down towards your anus and to the sides. You should feel a bit of a stretching feeling.

3. Hold this stretch for about one to two minutes.

4. Then gently massage the lower bit of your vagina for around two to three minutes, focusing on relaxing your perineum. Massage using your thumbs upwards and outwards then back again in a U-shaped movement. You could practice your slow, deep breathing techniques while you do this. (RCOG, no date) Repeat this two to three times (RCOG, no date).

5. Some people will focus the massage on any previous scar tissue.

Perineal massage shouldn't hurt, though you may feel pressure in the first few weeks of starting, which should ease.

5. Partner involvement

It can be difficult to massage your perineum by yourself in the later stages of pregnancy.

You might want to start off doing the perineal massage yourself. Then as you get nearer to the due date, if you feel comfortable doing so you could ask your partner to do it.

Simply follow the same method as before. The only difference is that your partner will use their index fingers rather than thumbs to perform side-to-side and U-shaped downward pressure.

6. Keep up the routine

Repeat daily or when possible.

Fit it into your daily or weekly routine, for example during or after a bath or shower. This is a good time because blood vessels in the area are already dilated, making the perineum softer and more comfortable to massage. You will also be more relaxed.

7. Support is available

Perineal massage shouldn't be painful although there might be some discomfort to begin with. If you're concerned about any pain, or you need further information or support with perineal massage, talk to your midwife or GP.

Abdelhakim, A.M., Eldesouky, E., Elmagd, I.A. et al. Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. Int Urogynecol J 31, 1735-1745 (2020). https://doi.org/10.1007/s00192-020-04302-8&nbsp;

Beckmann M, Stock O. (2013) Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. (4):CD005123. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005123.pub3/abstract;jsessionid=CF32264FB13246A8540B877017B34E8C.f02t04 [Accessed 1st September 2018]

Labrecque M, Eason E, Marcoux S. (2001) Women's views on the practice of prenatal perineal massage. BJOG. 108(5):499-504. https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/j.1471-0528.2001.00111.x [Accessed 1st September 2018]

Oxford University Hospitals NHS Trust (2017) Antenatal perineal massage. Available from:

https://www.ouh.nhs.uk/patient-guide/leaflets/files/10938Pmassage.pdf [Accessed 1st September 2018]

RCOG (no date) Reducing your risk of perineal tears. Available at : https://www.rcog.org.uk/en/patients/tears/reducing-risk/&nbsp;

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How to do perineal massage: a step-by-step guide | Pregnancy, Worries and discomforts articles & support | NCT

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So you know perineal massage might help you to avoid perineal tears and you're keen to try it out. Read on for our guide to how to massage your perineum.

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Your perineum is the area between your vaginal opening and back passage (anus).

It is common for the perineum to tear to some extent during childbirth.

Tears can also occur inside the vagina or other parts of the vulva, including the labia.

Up to 9 in every 10 first time mothers who have a vaginal birth will experience some sort of tear, graze or episiotomy. It is slightly less common for mothers who have had a vaginal birth before.

For most women, these tears are minor and heal quickly.

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Your perineum is the area between your vaginal opening and back passage (anus). It is common for the perineum to tear to some extent during childbirth. Tears can also occur inside the vagina or other parts of the vulva, including the labia.

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Most women will sustain some damage to their perineum during birth ( AIHW 2023). Around half will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). A quarter will be cut with episiotomy scissors. Occasionally (2% of non-instrumental vaginal births / 5.7% of instrumental births) significant tearing occurs that extends into the anal sphincter (3rd / 4th degree). This post will discuss 'protecting the perineum' and was initially based on a literature review. You can find the full literature review and reference list in my thesis. I have updated the post regularly since then and have added new references in the text.

Care providers often consider themselves to be 'perineal protectors' tasked with preventing women from tearing. There is currently a lot of effort and money being put into trying to reduce significant tearing (see this post). And of course the approach taken to 'protect the perineum' reflects the birth culture in general ie. that women's bodies are dangerous, and risk management involves carrying out interventions to minimise that risk. I think the truth is the other way around. What we do is usually the risk, and risk management should be about supporting physiology and instinct. Only intervening when there is a deviation from physiology.

Before we look at what the research says, bear in mind that research about birth outcomes is carried out on general populations i.e primarily on women having medically managed births. These types of births often involve interventions that increase tearing eg. syntocinon, directed pushing, instrumental birth etc. We don't have any good research about what protects the perineum during an uninterrupted, physiological birth where tearing rates are much lower.

Before birth

Fixed factors

Some factors that increase the chance of tearing are impossible or very difficult to control ( Dahlen et al. 2015):

a big baby

first vaginal birth

high weight gain in pregnancy

higher socioeconomic circumstances

older and younger maternal age

ethnicity (Caucasian and Asian)

short perineal body

nutritional status

abnormal collagen synthesis

Preparing the perineum for birth

Suggesting there is a need to 'prepare' for birth contradicts the fact that women's bodies are perfectly capable of preparing for birth without intervention. However, perineal stretching massage can increase some women's confidence in their body's ability to stretch and open for their baby. On the other hand, plenty of women don't prepare in this way, and whether you have confidence in your body or not, your perineum will stretch.

A number of guidelines recommend that women should be encouraged to massage their perineums during pregnancy to reduce the chance of tearing. The reference cited to support this recommendation is a Cochrane Review. However, the review did not conclude that massage reduced the chance of tearing. It found that women having their first baby who did perineal massage were less likely to have an episiotomy - not a tear. An episiotomy is an external factor and is dependent on the individual care provider rather than the woman's anatomy. Perhaps perineal massage helps women to fit unnecessary birthing timeframes prescribed by hospitals, therefore avoid being cut?

There are also perineal stretching devices being marketed to women. The websites for these products make bold unsubstantiated statements. One brand simply states figures with no citation. Another popular brand has a webpage listing 'studies'. However, these studies are pilot studies, study protocols or are very poor quality and old. Interesting, the only good quality research I can find into this device is not included on the brand website. This large RCT found that the stretching device did not reduce the chance of any type of perineal tearing, episiotomy, levator ani damage or anal sphincter trauma. Instead, it increased the rate of external anal sphincter damage. The researchers conclude that "antenatal use of the Epi-No device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma." Personally I worry about potential long term effects of repeatedly stretching the perineum to the size of a baby's head. Although a woman may give birth a number of times during her life, she will usually have more than a day between each baby's head stretching her vagina. I'd be interested to see some long term studies into pelvic floor outcomes after the use of these devices.

During birth

Birth is where all of the care provider activity focuses. It was seeing all of the fussing and fiddling carried out as babies were born that sent me in the direction of a PhD. I could not understand why such a physiological and instinctive bodily process required so much directing and doing. I still don't. I suggest that before (or after) you read this post, you read supporting women's instinctive pushing behaviour during birth. Of course, most women do not have an undisturbed birth, therefore are not necessarily connected in with what is going on in their body. In these cases it may be appropriate to intervene (with consent).

General factors known to increase the chance of tearing during birth are ( Dahlen et al. 2015):

position of baby - larger diameter of head presenting

midline episiotomy (see below)

instrumental birth (particularly forceps)

'prolonged second stage' - likely because this results in an instrumental birth

syntocinon (pitocin) use in women having their second or more vaginal birth

shoulder dystocia

The main principles involved in reducing the chance of tearing is the capacity for stretch and 'give' in the perineal tissues.

The location of birth is also a factor with hospital birth increasing the chance of perineal tearing.

Positions

Some birth positions assist with the principle above ie. the maximise the capacity for stretch. The two positions that involve the least chance of tearing ( side lying and hands/knees) do not involve stretched-wide legs and therefore stretched perineal tissue. In addition the pressure of the baby's head is towards the front of the mother rather than directly onto the perineum. In contrast, positions that make the perineum tight and stretched, and place all of the pressure of the baby's head directly onto the perineum increase the chance of tearing: semi-supine (sitting upright and reclined - the TV/film birth position); squatting; and lithotomy.

Many women will instinctively close their legs during crowning. I have seen midwives push women's legs back open or say 'keep your legs open'. Closing the legs, or bringing them in from a wide-open position protects the perineum. Try it yourself... open your legs wide and bring them up towards your chest - stranded beetle position - and feel what happens to your perineum. Now close your legs a little and bring them down away from your chest - feel how much more 'give' there is in your perineum when it is not stretched out. It can now respond to the stretch required by the baby's head without already being stretched out sideways. As for whether closing your legs will stop a baby from coming out... it may slow it down, but that baby is coming out. I have seen a woman birth on her side with her legs crossed - her baby came out from behind.

Standing up-right can result in a quick birth - particularly for women who have previously given birth - increasing the chance of tearing. It is not a position many women stay in to birth unless they have been directed to get into it.

Guidelines and training are reinforcing the need for the care providers to 'visualise the perineum' during birth. I'm not sure how that is supposed to prevent tearing. However, it does increase the chance the care provider will intervene. This approach is leading to more women being directed into positions to facilitate this - unfortunately positions that increase the chance of tearing.

Directed pushing

Guidelines recommend that 'good communication' is required between the care provider and woman to ensure a slow birth and minimise tearing. However, this is unnecessary if the woman is birthing instinctively. The intense sensations experienced during crowning usually result in the woman 'holding back' while the uterus continues to push the baby out slowly and gently. Often women will hold their baby's head and/or their vulva. I have witnessed one mother attempt to push her baby back in (you know who you are) - it was unsuccessful but gave us a giggle afterwards. Telling a woman to stop pushing, pant or 'give little pushes' distracts her at a crucial moment, and suggests that you are the expert in her birth, which you are not. She is the one with a baby's head in her vagina - leave it to her. Of course, if you have been shouting at her to 'Puuuush' with every contraction before crowning - she will be listening to you, not her body...

Warm water

Some women find having a warm compress held against their perineum as the baby crowns helps to ease the sensations of stretching. Others, hate it and find it intrusive. A Cochrane review found that warm compresses did not increase the chance of having an intact perineum or decrease the chance for suturing. However, it did reduce the chance of a very severe tear (3rd or 4th degree).

Waterbirth is another way of bathing the perineal tissue in warm water - and unlike warm compresses, makes it difficult for anyone apart from the birthing woman to touch her perineum or baby during birth.

'Hands on' techniques

Hands on techniques aimed at slowing the birth of the baby and supporting the perineal tissues are routinely used by many care providers. However, a systematic literature review concluded that: "The hands-poised [off] technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage." A Cochrane Review found that 'hands on' techniques did not reduce the chance of tearing and increased the chance of having an episiotomy. And a recent Australian study found that 'hands on' increased the chance of tearing for women having their second or more vaginal birth.

No research has explored women's experiences of a 'hands on' approach. And, I am yet to hear a midwife or obstetrician ask for permission before placing their hands on the woman and baby.

Perineal massage

Massaging the perineum as the baby is trying to be born concerns me for a number of reasons. It makes me really uncomfortable to watch lots of 'activity' being done to a woman's body while she is trying to birth. I have seen some very brutal versions of 'perineal massage' done to women; and I am guessing/hoping that most of the women in these studies had epidurals. However, the Cochrane Review above suggests that this type of massaging can reduce the chance of significant tears (3rd and 4th degree) not the usual (1st and 2nd degree). Significant tearing is rare (around 3%) - so the intervention needs to be weighed up with the risks of additional pain and disturbance to physiology. Also, in order to perform this intervention effectively the woman needs to be in a position that increases her chance of tearing ie. on her back / semi-reclined.

Episiotomy

An episiotomy involves a deep cut into the perineal muscles and skin ie. creating perineal trauma. Episiotomies used to be rare in midwifery practice. I have carried out three in my career, and with hindsight I think two were unnecessary. However, there is a resurgence thanks to a new wave of perineal focused intervention packages, and confusing research summaries and clinical guidelines.

For example, a Cochrane Review examining 'selective' vs 'routine' episiotomy concluded that: "In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal ." This seems to have been interpreted as 'selective episiotomy reduces severe tearing' rather than 'in comparison to routine episiotomy'. Interestingly, the review does not include information about what indications are included in a 'selective' approach, or the evidence supporting those indications.

There is some evidence about outcomes relating to the types of episiotomies used - mid-line (down toward the anus) vs medio-lateral (60 degree angle). A mid-line episiotomy contributes to the risk of severe perineal trauma by increasing the chance the cut will extend ( Lappen & Gossett 2014). However, a medio-lateral episiotomy cuts through more nerves and perineal structures ( Patel et al. 2018). We are only just beginning to understand the complex anatomy of the clitoris - a structure that is cut during a medio-lateral episiotomy. This type of episiotomy is associated "with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years" ( Dogan et al. 2017).

Even if episiotomy does reduces the chance of severe tearing (which we don't have the evidence for) - having an episiotomy during a non-instrumental vaginal birth would be trading a 2% chance of significant tearing with 100% chance of perineal damage via a cut.

After birth

Suturing

Tearing is a normal part of the birth process, and the body usually heals well. The vaginal wall is a mucous membrane and heals very fast (like the mouth). Suturing is the most common method of perineal repair. Whether to suture or not should be the woman's decision. In relation to 2nd degree tears (the most common) the need to suture is debatable if the tear aligns well and is not bleeding. A Cochrane Review concluded:
"...at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians' decisions whether to suture or not can be based on their clinical judgement and the woman's preference after informing them about the lack of long-term outcomes and possible chance of slower wound healing process, but possible better overall feeling of well being if left un-sutured."
In my own experience as a midwife found that un-sutured perineums heal very quickly and with far less pain than sutured perineums.

In summary

There is very little care providers can do to protect women's perineums using interventions. Instead, we need to encourage women to trust that their body has an innate ability to birth their baby; that perineal tearing is a normal part of birth; and that the body will heal itself.

If you enjoyed this post, you can find more of my work in the following resources:

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Updated: August 2023 Most women will sustain some damage to their perineum during birth (AIHW 2023). Around half will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). A quarter will be cut with episiotomy scissors. Occasionally (2% of non-instrumental vaginal births / 5.7% of instrumental births) significant tearing...

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1. Other birth outputs in this release

Other commentary from the latest births data can be found on the following pages:
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There were 624,828 live births in England and Wales in 2021, an increase of 1.8% from 613,936 in 2020, but still below the 2019 figure (640,370); 2021 remains in line with the long-term trend of decreasing live births seen before the coronavirus (COVID-19) pandemic.

The total fertility rate (TFR) increased to 1.61 children per woman in 2021 from 1.58 in 2020; the first time TFR has risen since 2012.

Fertility rates increased overall; however, younger age groups saw declining fertility rates while older age groups saw fertility rates increase.

There were 2,597 stillbirths in 2021, an increase of 226 from 2020; this is similar to the 2,522 stillbirths in 2019.

The stillbirth rate in 2021 increased to 4.1 stillbirths per 1,000 total births compared with 3.8 in 2020; this is also higher than the rate seen before the coronavirus pandemic in 2019 (3.9).

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3. Live births and fertility rates

For the first time since 2015, the number of live births in England and Wales increased annually. In 2021, there were 624,828 live births, an increase of 1.8% compared with 2020 (613,936). However, the number of live births in 2021 is lower than the number of pre-coronavirus (COVID-19) births in 2019 and is in line with the long-term trend of decreasing live births.

The total fertility rate (TFR) for England and Wales in 2021 rose to 1.61 children per woman. This is the first annual increase since 2012. The TFR is 1.9% higher than in 2020 (1.58), but 2.4% lower than in 2019.

Figure 1: Total Fertility Rate (TFR) increased slightly in 2021

Total Fertility Rate, England and Wales, 1939 to 2021

Source: Office for National Statistics - Births in England and Wales

Notes:

The total fertility rate is the average number of live children that a group of women would bear if they experienced the age-specific fertility rates of the calendar year throughout their childbearing lifespan.

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As discussed in our 2020 Births release, the TFR has been below replacement level since 1973 and TFRs have been decreasing year on year since 2012 (Figure 1).

Fertility rates increased overall in 2021, with the general fertility rate (GFR) rising to 55.8 births per 1,000 women in 2021, from 55.1 in 2020. Our provisional births data show how the GFR has varied over the pandemic period on a monthly basis.

However, when broken down by age groups, age-specific fertility rates (ASFRs) have increased in older age groups but decreased in younger age groups. The largest decrease was seen among those aged under 20 years (16%), whereas older women, aged 35 to 39 years, saw fertility rates increase by 5% (Figure 2).

Figure 2: In 2021, the overall increase in fertility has been driven by women at older ages when compared to 2020

Age-specific fertility rates, England and Wales, 1939 to 2021

Source: Office for National Statistics - Births in England and Wales

Notes:

For more information on the calculation of age-specific fertility rates see the Glossary.

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There were 2,597 stillbirths in England and Wales in 2021. This is a 9.5% increase compared with 2020 and similar to the 2,522 stillbirths seen pre-coronavirus (COVID-19) in 2019.

The stillbirth rate increased to 4.1 stillbirths per 1,000 total births in 2021, from 3.8 in 2020. This is higher than the pre-coronavirus rate (3.9 stillbirths per 1,000 total births) in 2019 (Figure 3). Further information on how stillbirth rates varied by month over the pandemic period can be found in the Provisional births 2021 release.

Figure 3: Stillbirth rate increased in 2021

Stillbirth rates, England and Wales, 1928 to 2021

Source: Office for National Statistics- Births in England and Wales

Notes:

Figures for stillbirths from 1993 are not fully comparable with those for previous years due to a definitional change, see Glossary.

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5. Fertility rates by geographic area

The total fertility rate (TFR) for England was 1.62 children per woman in 2021, increasing from 1.59 in 2020, an increase of 1.9%. Wales had a lower TFR, with 1.49 children per woman in 2021, the first annual increase in TFR in three years.

Fertility rates increased across all regions of England in 2021, except for London and the West Midlands. The region with the highest TFR was the East of England, with 1.76 births per 1,000 women, an increase from 1.69 in 2020.

Figure 4: Total fertility rate (TFR) by local authority district, England and Wales, 2001 to 2021

Notes:

1. The total fertility rate is the average number of live children that a group of women would bear if they experienced the age-specific fertility rates of the calendar year throughout their childbearing lifespan.

2. Figures are based on mothers' usual area of residence, based on boundaries as of May 2022.

3. The total childbearing population in some local authorities is small so any small change in the number of live births can result in a large localised TFR change.

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Please filter the explorable datasets for births in England and Wales, 2021 data will be added as soon as it is available:
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Age-specific fertility rate (ASFR)

The number of live births to mothers of a particular age per 1,000 women of that age in the population. Useful for comparing fertility of women at different ages or women of the same age in different populations. The rates for women under 20 years and 40 years and over are based on the female population aged 15 to 19 years and 40 to 44 years respectively. Age-specific fertility rates for 1981 are based on a 10% sample because of the late submission of some birth registrations caused by a registrars' strike. The population estimates used to calculate fertility rates from 1938 to 1980 are rounded to the nearest hundred and are therefore of a slightly lower level of accuracy than the fertility rates for 1981 onwards.

Live birth

A baby showing signs of life at birth.

Replacement level

Replacement fertility is the level of fertility required for the population to replace itself in size in the long term. In the UK, women would need to have, on average, 2.08 children to ensure long-term "natural" replacement of the population.

Stillbirth

A stillbirth is a baby born after 24 or more weeks completed gestation and which did not, at any time, breathe or show signs of life. On 1 October 1992 the Still-Birth (Definition) Act 1992 came into force, altering the definition of a stillbirth to 24 or more weeks completed gestation, instead of 28 or more weeks completed gestation.

Stillbirth rate

The stillbirth rate is defined as the number of stillbirths per 1,000 live births and stillbirths.

Total fertility rate (TFR)

TFR is the average number of live children that a group of women would have if they experienced the age-specific fertility rates for the calendar year in question throughout their childbearing lifespan. It is a better measure of trends than the number of livebirths, since it accounts for the size and age structure of the female population of childbearing age. The rate provides a timely measure of fertility levels and can be affected by changes in the timing of childbearing, completed family size and the population structure.

General fertility rate (GFR)

The number of live births in a year per 1,000 women aged 15 to 44 years. Measure of current fertility levels.

A more complete glossary is available from our User guide to birth statistics methodology.
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Our data are for live births and stillbirths occurring in each calendar year, plus late registrations for the previous year. Because of delays in birth registrations caused by the coronavirus (COVID-19) pandemic in 2020, the number of late registrations from the previous year included in the 2021 dataset was higher than usual but still accounted for less than 1% of all births and does not affect the headline trends discussed. Figures include mothers and fathers whose usual residence is outside England and Wales.

Birth statistics represent births that occur and are then registered in England and Wales. Figures are derived from information recorded when live births and stillbirths are registered as part of civil registration, which is a legal requirement. These data represent the most complete data source available.

The registration of births is a service carried out by the Local Registration Service in partnership with the General Register Office (GRO), in England and Wales. Birth registration is linked to the NHS birth notification within the Office for National Statistics (ONS) to obtain the age of the mother where this was missing on the birth registration. It also enables the analysis of further characteristics such as birthweight, ethnicity of the baby and gestation of live births.

More quality and methodology information (QMI) on strengths, limitations, appropriate uses, and how the data were created is available in our Birth statistics QMI.

Coronavirus and birth statistics

Delays in birth registrations because of the coronavirus pandemic affected 2020 and 2021 data; in normal circumstances, births should be registered within 42 days and our annual data extract only includes births registered before 25 February.

Birth registration services in England and Wales were temporarily suspended in March 2020. From June 2020 registration services restarted where it was safe to do so. In 2020, 42% of registrations came in after 42 days (the usual legal limit) and in 2021, 26% came in after 42 days. Therefore, we decided to include all births registered up to 12 August 2021 in the 2020 dataset and all births up to 15 May 2022 in the 2021 dataset, to ensure that our birth statistics are as complete as possible and comparable with previous years. For more information, please see our Births in England and Wales explained: 2020 article and our User guide to birth statistics methodology.
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9. Strengths and limitations

Our User guide to birth statistics methodology provides further information on data quality, legislation and procedures relating to conceptions, and includes a glossary of terms.

National Statistics status for Births in England and Wales

National Statistics status means that our statistics meet the highest standard of trustworthiness, quality and public value, and it is our responsibility to maintain compliance with these standards.

Date of most recent full assessment: September 2011.

Date of most recent compliance check, which confirms National Statistics status: September 2011

Improvements since last review include that:

revisions to the way statistics are produced are explained in the user guide, detailing the year the change took place and reason why

in cases where corrections were implemented, they were accompanied by explanations of the change and the reasons why

where applicable, we added additional background information into our User guide and QMI to inform the user of the differences in methods between the UK countries, and the reasons underlying these differences

following a consultation on proposed changes to statistics, we made changes in 2018 to the way that birth statistics are published, and five explorable datasets are now released alongside the first release of annual births data; this means more detailed births data (including small area geographies) are now available in a timelier manner

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Births in England and Wales - Office for National Statistics

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Live births, stillbirths and the intensity of childbearing, measured by the total fertility rate.

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1 in every 250 pregnancies ends in a stillbirth in the UK. That’s 8 babies every day. Find out more stillbirth statistics.

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Labour Pains - Information on pain relief choices during labour

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Information for expectant parents and healthcare professionals on pain relief choices during labour

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel hongkong memberikan setiap nomor keluaran hk hari ini dan angka pengeluaran hk malam ini akan selalu dirangkum ke dalam bentuk tabel data hk hari ini terlengkap. Hal seperti ini akan mempermudah togel hari ini hongkong dalam menyaksikan hasil angka keluaran hk hari ini hingga nomor pengeluaran hk malam ini. Saat ini, anda hanya perlu mencari kata kunci togel, maka anda sudah akan mendapatkan situs togel hari ini hongkong resmi yang menyediakan semua keluaran hk ataupun pengeluaran hk yang disusun kedalam tabel data hk. Hongkong pools merupakan satu-satunya situs resmi dari togel hongkong malam ini, dimana semua hasil nomor data keluaran hk hari ini diumumkan. Hanya untuk mendapatkan no pengeluaran hk dari situs hongkong pools, sudah begitu sulit di Indonesia. Alasan itulah, disini kami membuat sebuah website dengan menyediakan semua hasil togel hongkong pools terakurat yang kami rangkum dalam data hk terakurat.

Togel singapore merangkum semua nomor keluaran sgp hari ini dan pengeluaran sgp hari ini yang berasal dari situs resminya singapore pools sudah kami rangkum di data sgp terlengkap. Kini pemain togel singapore hari ini dapat melihat data keluaran sgp dan data pengeluaran sgp melalui halaman ini. Karena semua keluaran sgp hari ini maupun pengeluaran sgp hari ini melalui data sgp. Dengan sudah bekerja sama dengan situs togel singapore pools, maka data keluaran sgp maupun data pengeluaran sgp hari ini adalah no result sgp. Untuk itulah, para bettor dapat mempercayai halaman kami ini sebagai tempat untuk menyaksikan hasil keluaran sgp dan nomor pengeluaran sgp di Indonesia.

Togel sidney hari ini memiliki data keluaran sdy hari ini dan pengeluaran sdy hari ini secara resmi. Dengan menjadi satu-satunya tempat yang menyediakan nomor keluaran sdy hingga pengeluaran sdy hari ini langsung dari live draw sdy. Disini kami selalu tepat waktu dalam menyediakan keluaran sdy dan pengeluaran sdy pada jam result togel sidney. Dengan begitu anda sebagai pemain togel sidney dapat menggunakan situs kami ini sebagai tempat untuk menyaksikan hasil keluaran sdy ataupun pengeluaran sdy hari ini tercepat di Indonesia. Tidak sampai disini, bettor togel sdy di Indonesia dapat menggunakan tempat kami ini sebagai tempat acuan untuk menyaksikan keluaran sdy maupun pengeluaran sdy terakurat. Semua keluaran sdy dan no pengeluaran sdy sudah kami rangkum secara rapi dalam data sdy. Buat pemain togel sidney yang ingin menyaksikan keluaran sdy maupun pengeluaran sdy bisa secara langsung untuk mengunjungi situs kami ini ya, karena semua informasi togel hari ini sidney yang anda butuhkan semuanya sudah terkumpul di data sdy.

Togel hari ini menyediakan hasil data keluaran togel singapore hongkong sidney di Indonesia. Bagi pemain togel yang menggunakan no togel hongkong, togel singapore dan togel sidney sebagai menentukan nomor jackpot togel hari ini. Maka dari itu, para pemain togel akan setiap harinya mencari hasil data hk dengan pengeluaran sgp hingga keluaran sdy hari ini tercepat. Hanya dengan menyaksikan nomor result togel hari ini, para bettor bisa dengan mudah mendapatkan no togel hari ini. Lantaran bermain togel di Indonesia, saat ini sedang menjadi salah satu permainan terpopuler. Akan tetapi, hanya terdapat sebanyak tiga pasaran togel online resmi yang banyak diminati oleh para pecinta judi togel online seperti togel hongkong, togel sidney dan togel singapore.

Bermain togel hari ini pada pasaran togel singapore, togel hongkong hingga togel sidney memang menjadi pasaran terpopuler di tanah air. Sebab itu, kami membuat halaman ini untuk memberikan semua hasil keluaran togel hari ini paling akurat. Dengan nomor keluaran sdy hk sgp dan pengeluaran sgp hk sdy hingga data hk sgp sdy tepat waktu dari pasaran togel hongkong, togel sidney dan togel singapore hari ini.

Info Togel Pengeluaran SGP Melalui Data Hk Hingga Keluaran Sdy Hari Ini

Keluaran sdy menjadi nomor main togel sidney terakurat. Dimana setiap pemain bisa menyaksikan semua data pengeluaran sdy untuk referensi nomor main togel sidney hari ini. Jadi sudah tidak mengherankan lagi, kalau setiap jadwal keluaran sdy pemain selalu mencari situs togel online yang menyediakan hasil keluaran sdy. Oleh karena itu, secara tidak langsung anda bisa mengandalkan situs kami ini sebagai tempat untuk menyaksikan keluaran sdy dan pengeluaran sdy yang ada di data sdy sebagai nomor togel sidney resmi di Indonesia.

Pengeluaran sgp hari ini diumumkan oleh pihak togel singapore pools setiap jam 17.45 wib. Dengan tepat waktu anda bisa melihat data keluaran sgp hari ini. Karena disini kami memberikan layanan togel hari ini singapore pools terpercaya. Untuk itu semua data pengeluaran sgp dan keluaran sgp tentunya terpercaya sebagai no result togel singapore hari ini. Informasi togel kami adakan melalui data sgp dengan semua history angka keluaran sgp hari ini.

Data hk hari ini terlengkap sudah kami sediakan melalui tabel keluaran hk pools. Dengan cara seperti ini pemain togel hongkong bisa sesegera mungkin menggunakan hasil pengeluaran hk dan keluaran hk kami sebagai acuan untuk menyaksikan nomor keluaran hk hari malam ini. Disini kami langsung menyediakan togel hongkong pools melalui situs resminya. Dengan tersedianya data hk hari ini melalui keluaran hk malam ini, para pemain dapat memanfaatkan data hk menjadi angka hk jitu terakurat. Cuman melakukan pengumpulan semua data keluaran hk terlengkap untuk dipergunakan sebagai referensi terbaru. Jadi para bettor togel hongkong lebih dipermudahkan untuk mendapatkan hasil jackpot hongkong menggunakan data hk dari hasil pengeluaran hk malam ini.

Info togel yang tersedia disini menjadi informasi togel hari ini terpercaya untuk melihat no togel terlengkap di Indonesia. karena pada halaman ini menyediakan semua no pengeluaran sgp, data hk hingga keluaran sdy hari ini. Khusus pemain togel online yang selalu bermain ketiga pasaran togel hari ini. Kini anda sudah bisa menyaksikannya melalui tempat kami ini agar lebih mudah mendapatkan semua data pengeluaran sgp dan data hk hingga keluaran sdy hari ini. Hal ini dikarenakan live draw hk, live draw sgp dan live draw sdy masing-masing melakukan hasil result togel hari ini dengan waktu yang berbeda. Untuk member yang selalu mencari keluaran sdy, pengeluaran sgp dan data hk melalui masing-masing situs yang berbeda, hal seperti ini hanya akan membuang waktu anda saja. Jadi dengan hadirnya halaman kami ini, anda sudah bisa melihat semua no result togel hongkong dan togel singapore maupun togel sidney secara langsung hanya dengan satu situs yang menyediakan keluaran togel hari ini terlengkap.

Angka Keluaran Togel Hk, Togel Sgp Dan Togel Sdy Di Indonesia

Tahun ini semua member togel online sudah dapat menggunakan satu website untuk melihat angka keluaran togel hk, togel sgp dan togel sdy di Indonesia. Ketiga pasaran togel resmi tersebut menjadi tujuan utama dalam bermain judi togel online di Indonesia. Pada masa kini, kami sudah membuat sebuah situs yang hanya memberikan angka keluaran sdy dan pengeluaran sgp hingga data hk hari ini. Tentunya situs kami ini merupakan situs resmi yang memberikan hasil togel hongkong, togel singapore maupun togel sidney sebagai hasil info togel hari ini.

Togel hk banyak disebut sebagai togel hongkong, togel hkg ataupun toto hk. Togel hk menyediakan keluaran hk maupun pengeluaran hk sebagai nomor result togel hongkong asli. Para pemain bisa dapat melihat semua keluaran hk hari ini melalui tabel data hk yang sudah kami sediakan diatas. Semua barisan keluaran hk hingga pengeluaran hk kami tayangkan secara langsung pada setiap hari ini. Jadi bagi anda yang merupakan pemain sejati dari togel hongkong dapat mempergunakan tabel keluaran hk hari ini sebagai referensi untuk menyaksikan pengeluaran hk terbaru.

Togel sdy dikenal sebagai togel sidney hingga toto sdy. Togel sdy hari ini menyediakan siaran live draw sdy pada situs resmi sydney pools dan disini kami mengupdate semua hasil keluaran sdy hingga pengeluaran sdy pada tabel data sdy. Jadi buat hasil keluaran sdy dan pengeluaran sdy hari ini semuanya melalui result togel sdy terakurat. Hanya melalui nomor togel hari ini sidney para pemain bisa mendapatkan data keluaran sdy hari ini dari togel sdy pools. Sebab itu, kepada anda semua yang ada diluar sana, yang masih belum menyaksikan nomor result pengeluaran sdy bisa mengunjungi situs kami ini.

Togel sgp banyak dikenal dengan sebutan togel singapore maupun toto sgp. Dimana togel sgp ini dimainkan oleh semua petaruh togel online di Indonesia. Buat bettor pastinya akan membutuhkan no pengeluaran sgp dan keluaran sgp hari ini. Jadi halaman kami ini pas banget untuk anda gunakan dalam mendapatkan data pengeluaran sgp dan data keluaran sgp hari ini di Indonesia. Secara pribadi disini kami sudah berhubungan langsung dengan pihak togel sgp pools. Jadi sudah jelas untuk semua angka keluaran sgp maupun pengeluaran sgp hari ini resmi berasal dari togel singapore pools.

Dapatkan Semua Keluaran SDY, Pengeluaran SGP Dan Data HK Hari Ini

Para pemain togel hari ini tentunya sangat membutuhkan situs yang bisa dipercaya yang memberikan data hk, pengeluaran sgp dan keluaran sdy hari ini di Indonesia. Karena kebanyakan orang Indonesia cuman ingin bermain togel online dari ketiga jenis pasaran togel resmi. Untuk itu, para pemain harus bisa menemukan secepat mungkin data hk dari togel hari ini, pengeluaran sgp dari togel singapore hari ini hingga keluaran sdy dari togel sidney hari ini. Oleh itu kami disini membuat situs dengan menyediakan langsung ketiga pasaran togel hari ini di Indonesia hanya untuk anda semua. Disini anda bisa langsung menemukan situs halaman kami ini di mesin pencarian google dengan cara mencari kata kunci togel pada smartphone anda masing-masing. Dengan begitu para pecinta judi togel online sejati bisa menggunakan pencarian google untuk menyaksikan hasil keluaran togel hari ini yang ada di Internet.

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel Hongkong - Togel Singapore - Togel Sidney - Keluaran SDY - Pengeluaran SGP - Data HK Hari Ini

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Togel hongkong togel singapore togel sidney merupakan pasaran togel hari ini terpopuler yang memberikan hasil keluaran sdy pengeluaran sgp dan data hk hari ini.

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In this video, we're going to talk about using a doula for pain relief during labor.

Hi, everyone. My name is Rebecca Dekker. I'm a nurse with my Ph.D. and the founder of evidencebasedbirth.com. I've written extensively about the evidence on doulas and the research supporting their use. You can find that info at ebbirth.com/doulas, but, in today's video, I want to focus in on using a doula for pain relief during labor and childbirth.

What is a birth doula?

For those of you who don't know, a birth doula is a companion who provides people with continuous support during labor and birth.

How do doulas provide pain relief during childbirth?

There are four different ways that doulas can affect pain management. These include physical support, emotional support, childbirth preparation/information, and advocacy.

Physical Support

Doulas are trained to provide physical support through the use of soothing touch and massage. They make sure that the laboring person is as comfortable as possible. This might include the use of movement and positioning, which we talked about in a different video, which is a very effective pain management technique. Physical support may also include the use of pressure on your back during contractions (called the counter-pressure), and helping to keep you nourished with ice chips, food and drinks. Other comfort measures may include fanning you if you get hot, giving you a cold, wet washcloth if you feel nauseous, providing you with pillows, ChapStick, music - anything you need to keep you comfortable.

Emotional Support

Doulas also provide emotional support, which helps the mother to manage pain during childbirth. Doulas work to create a calm birth environment. As we discussed in our video about painless birth and pain perception, the hospital birth environment today can cause stress, which can increase your perception of pain. Doulas work to help decrease that stress in the birth room. They give you encouragement and praise and remind you that you are safe and supported.

Doulas work with the birth partner (e.g., spouse, boyfriend, girlfriend, family member or friend) to help that birth partner better support you. Researchers have found that when people feel capable, confident and cared for, they feel less pain during labor. They perceive their pain as more manageable and they're better able to cope.

Doulas also help mothers to interpret labor in a positive way, by reminding them that the sensations they're feeling are productive and purposeful and that each wave or contraction is helping to bring the baby down and out. Research shows that when mothers view their contractions in this way, they're more likely to perceive them as less painful.

There's a researcher in Sweden named Kerstin Uvnäs Moberg, who's an expert in oxytocin, which is the hormone that most of us know about that causes contractions. It's also known as the "love" hormone. She writes that doulas facilitate oxytocin release, which decreases your stress, fear or anxiety and increases the effectiveness of your contractions. In addition, the calming effect of the doula's presence increases the mother's own natural pain-relieving hormones, also known as endorphins. All together, these things make labor feel less painful.

Childbirth Preparation and Providing Information

Childbirth preparation is another way that doulas can help to decrease pain. Doulas help pregnant people and their partners prepare for childbirth through education, information, practicing coping skills and counseling at prenatal visits. They help them talk through their fears and suggest coping techniques that they can use such as breathing, relaxation, movement and changing positions.

Researchers have found that both childbirth classes and support from a doula help lower pain perception during labor. This mechanism of pain relief is called Central Nervous System Control, and we talk about it in detail in our overview video all about pain management during labor. Central Nervous System Control causes the mother to perceive pain as less unpleasant by activating the parts of the brain responsible for memory, emotions and reaction to pain.

Advocacy

Finally, advocacy is another way that doulas can help decrease pain. Doulas typically don't speak up for you, rather, they encourage you to speak up for what you want. This advocacy technique may be helpful in relieving your pain. For example, if a mother is coping well in an upright mobile position and the care provider insists that she get back in bed even though things are progressing normally, the doula could facilitate communication between the woman and the care provider by asking the woman which position she prefers.

What's the evidence on using a doula for pain relief?

There have been at least 26 randomized, controlled trials that tested the effects of continuous labor support on more than 15,000 people total. These studies were included in a Cochrane Review published in 2017. People in these studies were randomly assigned to either receive one-to-one continuous support from someone or "usual care." The type of support provided could be from a member of the hospital staff, a doula, a childbirth educator, a retired nurse, or a family member or friend.

The researchers found that, overall, people who received continuous support during labor - meaning that someone never leaves their side - experienced a 25% decrease in the risk of having a Cesarean. The largest decrease in the risk of Cesarean was seen with a doula; using a doula lowered the risk of Cesarean by 39%. Continuous support led to an 8% increase in the likelihood of a spontaneous vaginal birth. Again, the largest effect was seen with doulas; using a doula increased the chance of a spontaneous vaginal birth by 15%.

Having continuous support during childbirth was also linked to a 31% decrease in the risk of being dissatisfied with your childbirth experience. Mothers' risk of being dissatisfied with their experience was decreased if they received continuous support from a family member, friend or a doula, but not if they received continuous support from hospital staff. With continuous support, they also found a 10% decrease in the use of any pain medications during labor, shorter labors by about 41 minutes on average, and a 38% decrease in the risk of your baby having a low Apgar score. Researchers did not find any difference between groups with the rates of Pitocin augmentation or special care nursery admissions.

There is one new randomized, controlled trial that was published in 2017 and was too new to be included in the Cochrane Review. In this study that took place in Iran, researchers conducted a randomized, controlled trial to test the effects of doulas on pain and anxiety levels in first-time mothers who were giving birth. The mothers were assigned randomly to either have a doula or to not have a doula. They used standardized questionnaires to measure anxiety and pain. They found that, on average, the mothers who had doula support experienced less anxiety during labor and less pain. The authors concluded that the doula's presence has a clinically meaningful impact on both pain and anxiety during labor. They recommended that all hospitals and maternity care centers in their country provide access to doulas, since they believe that having a safe and calm delivery is a human right.

How do you find a doula?

In the resources section below, I will provide a link to Childbirth Connection, which has a great list of questions you can ask if you're interviewing a doula. Even if you're not sure if using a doula for pain relief is right for you, sometimes it helps to interview several and just see if you find someone who really clicks with you.

Also, doulamatch.net is a great way to find a doula. Doulas upload their availability to that website on a regular basis, so you can find if there is somebody in your area who's available for the time around your due date.

Conclusion

In summary, out of all of the possible ways that we can help people manage pain during labor and childbirth, using a doula for pain relief seems like one of the most important. Doulas provide physical support, emotional support, childbirth preparation and advocacy - all of which can help decrease pain.

Providing doula support to birthing people is a risk-free endeavor, and it's highly effective for improving health outcomes such as decreasing your risk for Cesarean or forceps or vacuum delivery. People who use a doula report experiencing less pain and anxiety during labor. They're also much more likely to be highly satisfied with their birth experience.

In one study that looked at giving couples a doula, they found that all of the partners rated their experience with a doula as positive or extremely positive. So, typically, both the birthing people and their partners are highly satisfied with the help they got from their doula.

The bottom line is that using a doula for pain relief should be an option for all birthing people since doulas are a valuable, evidence-based member of the birth care team.

That's it for this video. Thanks and bye!

To learn more and subscribe to our newsletters for useful information, please visit evidencebasedbirth.com.

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Using a Doula for Pain Relief - Evidence Based Birth®

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Today's video is all about using a doula for pain relief! Are you familiar with birth doulas? Find out how they provide pain relief during labor and childbirth. Learn about the evidence for using a doula for pain relief. We'll also share some ways that you can locate a doula.

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‎The Midwives’ Cauldron: An interview with Lyndsey Hookway - all things infant sleep! on Apple Podcasts

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‎Show The Midwives’ Cauldron, Ep An interview with Lyndsey Hookway - all things infant sleep! - 1 Dec 2022

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Your midwife and obstetrician will be aware that in every birth there is a possibility of shoulder dystocia.

Shoulder dystocia is an emergency and therefore, when it does occur, speed is of the essence. The baby's shoulder needs to be released quickly so that the baby's body can be born and he or she can start breathing air into the lungs. Your midwife will push the emergency bell and three or four members of staff, including obstetricians, midwives and a doctor for the baby (paediatrician), are likely to come into the delivery room to help.

Because it happens so quickly and lots of people come into the room, it may be frightening for you and your birth partner. However, it is important to remember that obstetricians and midwives who attend the birth are trained in how to release the shoulders using certain manoeuvres and in the great majority of cases your baby will be delivered promptly and safely.

The obstetrician or midwife will usually:

ask you to stop pushing

reposition you to give your baby more room inside the vagina; you will be asked to lie on your back with your legs pushed outwards and up towards your chest (this is known as the McRoberts manoeuvre)

press on your abdomen just above the pubic bone to try to release your baby's shoulder

consider making a cut (episiotomy) to enlarge the vaginal opening.

With these simple measures, the majority of babies are born safely.

If the shoulder is not released easily with the above measures, either:

your obstetrician or midwife will put his or her hand within the vagina to try to free your baby's shoulder, or

you may be helped to roll over onto 'all fours', which can also help to release the shoulder.

Once the shoulders are free, your baby will be born, and a paediatrician will examine him or her. Your midwife and obstetrician will talk to you about what happened. If you wish to talk at a later date about your experience, ask to talk to your obstetrician, midwife, health visitor and/or GP.

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Shoulder dystocia patient information leaflet

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This information is for you if you wish to know about shoulder dystocia. You may also find it helpful if the birth of your baby was complicated by shoulder dystocia. It may be helpful if you are a partner, relative or friend of someone who has been in this situation.

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Induction for big baby: what’s the evidence? - Dr Sara Wickham

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Being offered induction for big baby? Dr Sara Wickham shares the evidence and the things you might want to consider.

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How Every Child Can Thrive by Five | Molly Wright | TED

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How a child's brain develops through early experiences

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Learn how to boost your baby's brain from a Harvard Professor | UNICEF

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Baby Check App

Baby Check features 19 simple checks that parents can do if their baby is showing signs of illness. Each check tests for a different symptom and when completed, a score is calculated that tells parents or carers how ill their baby is. The app then lets parents know whether their baby needs to see a doctor or health professional.

Download for FREE from Google Play or the App Store.

Buy posters, business cards and other materials to help promote Baby Check to your clients and patients

Shop

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The Baby Check App helps parents decide if their baby needs to see a doctor or health professional

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Group B Strep resources - Dr Sara Wickham

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This post offers links to all of the group B strep resources on Sara Wickham’s website, including articles, blog posts and a few external resources.

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If you have just tested for group B Strep carriage, whatever the result, please don't worry.

Carrying GBS is perfectly normal and natural and does not post a health risk or cause symptoms in the person carrying the bacteria.

If you're pregnant and know you carry GBS, you can take steps to minimise the relatively small chance that your baby will develop GBS infection. (If you're not pregnant, you can find out more here.)

If you did a private test, it is important to tell your doctor/midwife the result, whether it's positive or negative.

If group B Strep has been found during your pregnancy from a vaginal or rectal swab, treatment is NOT recommended until labour starts, when you should promptly be offered intravenous antibiotics*.

If group B Strep has been found from a urine sample during your pregnancy, you may have a urinary tract infection. If so, you should be given antibiotics to treat it. You should also be offered intravenous antibiotics when labour starts*.

There's no evidence that taking antibiotics for GBS carriage before labour reduces GBS infection in newborn babies. The antibiotics have been shown to be highly effective at preventing GBS infection in newborn babies when they're given as soon as possible once labour has started and then at regular intervals until the baby is born. This dramatically reduces the risk of GBS infection in a newborn baby.
*All UK national guidelines recommend that Mum should be offered intravenous antibiotics in labour if GBS has been detected during the current pregnancy. Hear how Fiona Gibson found out about group B Strep, was tested, had antibiotics in labour and how baby Nate was born fit and healthy.
If you're not pregnant and GBS carriage has been detected, then you don't need to do anything. Carrying group B Strep is normal.

Are my vaginal symptoms caused by group B Strep?

We know of no convincing evidence that shows carrying GBS causes vaginal symptoms (although GBS can and does causes infections, including urinary tract infections, which do often have symptoms). GBS detected from a vaginal swab means the vagina was colonised with GBS when the swab was taken - it does not mean GBS is the cause of any symptoms being investigated. Carrying GBS is not associated with vaginal symptoms.

How reliable are my test results?

Group B Strep carriage status can change over longer periods of time. In countries which routinely test all pregnant for group B Strep, this is usually done between 35 and 37 weeks of pregnancy.

A Positive Test Result

A positive test result is highly reliable. Any positive test result (NHS or private) is a very strong indicator that GBS was present when the samples were taken. It is very unlikely that a test will give a falsely positive result (i.e. finding group B Strep when it's not present).

A Negative Test Result

The reliability of a negative result from a test for group B Strep carriage depends both on where the samples were taken from, and on what method was used to process those samples.

If you were taking or had recently finished taking antibiotics when your samples were taken, this may affect your test results - speak with your midwife or doctor about this.

If an NHS 'standard' test result is negative

A negative group B Strep result from a standard NHS swab test is not reliable - this test gives a high proportion of false-negative results. This test only finds group B Strep about half the times it is present, so around half (50%) of those carrying group B Strep will be incorrectly told they are not.

If an ECM test (private or NHS) result is negative

A negative group B Strep result from an ECM test is highly reliable. Research has found that, when the ECM (Enriched Culture medium) test was properly performed within 5 weeks of the mother giving birth, a negative result was 96% predictive that she would not be carrying group B Strep when she gave birth (so only 4% of women acquired GBS carriage between the test and giving birth).
Read more about the different tests used to detect group B Strep here.
What are my options for where I give birth to my baby?

You can write a birth plan to help you tell your healthcare team what kind of labour you'd like, both what you would like to happen and what you wish to avoid. Carrying group B Strep does not always mean you need to change your birth plan.

You should discuss your planned place of birth with your doctor or midwife during pregnancy to make sure that you can have the antibiotics in labour to protect against GBS infection in your newborn baby.

Penicillin G is the antibiotic usually given (alternatives are available for women who are allergic to penicillin). Penicillin G is given intravenously (IV) for 15-30 minutes every four hours, and it may not be possible to arrange this at home or in some midwife-led units (particularly stand-alone units). It is really important that you tell your health professionals if you have ever had an allergic reaction to penicillin or any other antibiotic.

You should let your doctor or midwife know if you have previously had a baby who had group B Strep infection or if you have had a positive result for a group B Strep test in this or a previous pregnancy.

As soon as you go into labour or your waters break, contact your health professional as, if you carry GBS and have decided to have the antibiotics, it is important that you have the first dose as soon as possible.

If you choose to have the antibiotics in labour, you should still be able to move around freely.

Click below to read more about:-

I have been offered a membrane sweep. Is it safe for women who carry group B Strep?

There is no good evidence that membrane sweeps are harmful in women who carry GBS. The results of trials of membrane sweeps don't show any increase in problems caused by GBS in women having sweeps, and it is highly likely these trials would have included many women carrying GBS.

There does remain a theoretical risk that a membrane sweep might occasionally introduce GBS into the uterus. Our medical advisory panel, therefore, advises caution in using a membrane sweep for women carrying GBS when there are other acceptable alternatives (for example, induction of labour with prostaglandin gel introduced into the vagina).

What are the signs that group B Strep is affecting my unborn baby?

Although uncommon, GBS can cause infection of a baby in the womb, which can result in preterm birth, stillbirth and late miscarriage. Thankfully, this is not common since both the mother and her baby have natural defences against the baby developing GBS infection before labour starts or waters break. If your pregnancy is progressing normally, there is no reason to suspect group B Strep is infecting your baby.

In the unlikely event that a GBS infection does develop, labour will usually start or the membranes will rupture. This is the time to get to the hospital as quickly as you can to receive the intravenous antibiotics to give your baby the best protection possible.

If you are concerned about anything when you're pregnant (including if you experience reduced fetal movements which can be a sign that the baby is in distress), you should seek advice from your midwife in the first instance. If she's not available, then contact your maternity unit - they're there to help you.

If group B Strep has been found, when should I have antibiotics?

If group B Strep has been detected from a vaginal or rectal swab, antibiotics will not be given until your labour starts - treating carriage with antibiotics before labour begins does not reduce the chance of your baby developing group B Strep infection.

When labour starts you will be offered intravenous (IV) antibiotics. These antibiotics reduce the risk of your baby developing a GBS infection in their first week of life by 85-90%, from around 1 in every 400 babies born to around 1 in 4000.

If group B Strep has been found in your urine, you may need antibiotic tablets as you may have a urinary tract infection (UTI). You will also be offered IV antibiotics once labour starts to protect against group B Strep infection in your newborn baby.

If you have had a previous baby who developed a group B Strep infection, you should always be offered IV antibiotics during labour in future pregnancies, as there is an increased risk that a future baby may also be affected.

There are other situations where you will be offered antibiotics but these are not specifically related to group B Strep infection:

If your waters break preterm (before 37 weeks) and you are not in labour, you may be offered antibiotics. See the Royal College of Obstetricians & Gynaecologists's information leaflet: https://www.rcog.org.uk/en/patients/patient-leaflets/when-your-waters-break-prematurely/. You may also be interested in the National Institute of Health and Care Excellence (NICE) guidance NG25 on Preterm Labour and Birth: https://www.nice.org.uk/guidance/ng25/chapter/Recommendations

If you are having a planned Caesarean birth and you carry group B Strep, you do not need group B Strep-specific IV antibiotics unless labour has already started or your waters have broken. All women having a Caesarean birth will be offered antibiotics at the time of the operation to reduce the risk of a wide range of infections, including group B Strep.

If I carried group B Strep in a previous pregnancy, should I be given IV antibiotics during labour?

If group B Strep was detected in a previous pregnancy and your baby did not develop a group B Strep infection, there is a 1 in 2 (50%) chance that you will be carrying group B Strep again this pregnancy. To help you choose whether you would like to have IV antibiotics in labour, you can have a specific swab test (known as the Enriched Culture Medium or ECM test) to see whether you are carrying GBS when you are 35-37 weeks pregnant.

Clinical guidelines recommend that you should be offered this ECM test by the NHS, but we know that some NHS hospitals do not yet offer ECM tests. If your hospital is unable to offer ECM testing, you may choose to purchase an ECM test privately.

If the result shows that:

you are carrying group B Strep, then the risk of your baby developing early-onset group B Strep infection is increased to around 1 in 400 and you will be offered IV antibiotics in labour.

you are not carrying group B Strep, then the risk of your baby developing early-onset group B Strep infection is much lower (1 in 5000) and you may choose not to have IV antibiotics in labour.

What will my treatment during labour involve?

If you have been offered IV antibiotics to prevent group B Strep infection in your newborn baby, these should be started as soon as possible after your labour begins or your waters have broken. They are given intravenously by a cannula usually in the back of your hand, and at regular intervals (every 4 hours if you're being given Penicillin G, with different intervals for the antibiotics recommended for women who are allergic to penicillin) until your baby is born.

You should still be able to move around during labour, and the IV antibiotics should not stop you from having a water birth.

If your waters break before you go into labour, your doctor or midwife will talk to you about when you will need IV antibiotics and about the best time for your baby to be born. This will depend on your individual circumstances and on how many weeks pregnant you are.

Can IV antibiotics in labour cause any harm?

Some women may experience temporary side effects, such as feeling sick or having diarrhoea. Women can be allergic to certain antibiotics and, in rare cases, the reaction may be severe or even life-threatening (anaphylaxis). However, this is very rare - in the USA between 1997 and 2001, an estimated 1.8 million women were given penicillin in labour and no deaths from anaphylaxis were reported.

Tell your doctor or midwife if you know that you are allergic to penicillin or any other medications.

Your doctor or midwife should discuss both the benefits and the risks of taking IV antibiotics in labour to prevent early-onset GBS infection in your baby with you.

If you choose not to have IV antibiotics in labour, your baby will be monitored closely for 12 hours after birth, as they are at increased risk of developing early-onset group B Strep infection.

I don't want antibiotics in labour - are there natural alternatives?

Our medical advisory panel members have looked into alternatives, but are not persuaded that any therapy other than antibiotics in labour is effective in preventing early-onset GBS infection.

One question we have been asked a lot recently is whether raw garlic inserted vaginally reduces the likelihood of GBS infection in a newborn baby. There is no good evidence that garlic will prevent GBS colonisation and, since the reservoir for GBS colonisation is the gut, garlic vaginally won't impact colonisation there. Similarly, there is no good evidence that garlic will prevent GBS infection in a baby.

Although the subject of much discussion, there are no natural, homoeopathic or alternative medicines for which there is good research showing that they are effective at preventing group B Strep infection in newborn babies. If this changes, we'll issue an update.

If you have any questions about Group B Strep, please call our helpline
Mon-Thu 9am-3pm, Fri 9am-12pm
0330 120 0796

Or email us at info@gbss.org.uk

Read more about preventing GBS infection in your baby during labour and birth

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What does my test result mean? - Group B Strep Support

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If you have just tested for group B Strep carriage, whatever the result, please don't worry. Carrying GBS is perfectly normal and natural and does not post a health risk or cause symptoms in the person carrying the bacteria.

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Shared Decision Making

If you are asked to make a choice, you may have lots of questions that you want to ask. You may also want to talk over your options with your family or friends. It can help to write a list of the questions you want answered and take it to your appointment.

Ask 3 Questions

To begin with, try to make sure you get the answers to 3 key questions, if you are asked to make a choice about your healthcare:

1. What are my options?

2. What are the pros and cons of each option for me?

3. How do I get support to help me make a decision that is right for me?

*Ask 3 Questions is based on Shepherd et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: A cross-over trial. Patient Education and Counselling, 2011;84:379-85

https://www.aquanw.nhs.uk/sdm

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Group B Streptococcus (GBS) in pregnancy and newborn babies

# data[].attributes.attachment_link.description
Shared Decision Making If you are asked to make a choice, you may have lots of questions that you want to ask. You may also want to talk over your options with your family or friends. It can help to write a list of the questions you want answered and take it to your appointment.

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Intrapartum antibiotics for known maternal Group B streptococcal colonization

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Maternal colonization with group B streptococcus (GBS) during pregnancy increases the of neonatal infection by vertical transmission. Administration of intrapartum antibiotic prophylaxis (IAP) during labor has been associated with a reduction in early onset GBS disease (EOGBSD). However, treating all colonized women during labor exposes a large number of women and infants to possible adverse effects without benefit.

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Updated on February 6, 2023, and originally written June 6, 2014 by Rebecca Dekker, PhD, RN

Get our free, one-page handout on GBS today to use in your informed decision making!

In some countries, pregnant people are tested for Group B Streptococcus (Group B Strep or GBS) bacteria towards the end of pregnancy. If a pregnant person is a carrier of Group B Strep (sometimes called "colonized with GBS") and not treated with appropriate antibiotics during labor, then there is a 1-2% chance that their baby will develop early GBS disease.

Early GBS disease is a serious illness in the first week of life that can result in a long and expensive stay in a Newborn Intensive Care Unit (NICU) (Steer et al. 2020). Group B Strep was first recognized as a widespread threat to newborns in the early 1970's. At that time, 1.7 of every 1,000 infants born in the U.S. had early GBS disease ( CDC 2010). Today, because of a major public health campaign called "universal screening," early GBS disease is much rarer in U.S.-born infants, but it is still a leading cause of newborn illness and death in other places around the world.

The topic of Group B Strep can be controversial. In high-resource countries where some people face excessive medical care and overuse of interventions, using preventive antibiotics for the one-third of people who have a positive test-when it will not lead to illness for 98-99% of their infants-can be seen as unnecessary by some. They may have legitimate concerns about the overuse of antibiotics and the negative effect of antibiotics on a baby's microbiome.

Meanwhile, some health care workers may get frustrated when parents who are GBS positive decline antibiotics, because if one facility has thousands of births per year, a 1-2% chance (which seems low to individual parents) could translate into dozens of sick babies who need intensive care.

In other places around the world (sometimes even within high-resource countries), marginalized groups of people are not provided basic health care options, such as accurate testing for Group B Strep, IV antibiotics, or medical help when they or their infants experience serious illness or complications. In those places, GBS is still a leading cause of newborn death.

So, what is Group B Strep, and why do health care providers worry about newborn GBS disease? Does the evidence support testing for GBS and giving IV antibiotics during labor to prevent newborn infections? What are the benefits and risks of IV antibiotics? What is the microbiome, and how is it impacted by antibiotics given during labor? Are there any alternatives to GBS testing or treatment?

In this updated version of the Evidence Based Birth® Signature Article, we provide a global perspective on Group B Strep, as well as an explanation of how GBS and antibiotics relate to the microbiome. As a content note, we will discuss stillbirth, infant death, critical illness of newborns, and disparities in access to health care.

Group B Streptococcus is a type of bacteria that naturally lives in the large intestine and can migrate down to the rectum, vagina, and urinary tract, usually without causing illness. All around the world, about 18% of pregnant people carry GBS in their bodies (Russell et al. 2017). However, carrier rates can be as low as 8%, or as high as 35%, depending on the part of the world that you live in and how common Group B Strep is in the bodies of people living there.

During most of your life, if you carry Group B Strep, it is considered physiological, or normal (ACOG 2019). However, GBS can cause infections during time periods when your immune system is not functioning at its highest, such as when you're very young, or if you have a chronic illness, or when you are very old (Steer et al. 2020). These infections are called GBS disease.

In pregnancy, GBS can sometimes lead to urinary tract infections (UTIs), preterm birth, and stillbirth. However, it is somewhat uncommon for GBS to cause infections in pregnant people-it is the cause of only 1-2% of UTIs in pregnancy, and only about 1-2% of stillbirths (Steer et al. 2020).

For newborn babies whose immune system is not yet mature, GBS can cause a serious disease that usually requires a stay in the NICU (Puopolo et al. 2019).

There are two main types of GBS disease in newborns: early onset GBS disease (< 7 days of life) and late onset GBS disease (1 week through 3 months). Some newborns can also become carriers of GBS as well, but not develop sickness. In this article, we will be focusing on early onset GBS disease.

To prevent early GBS disease in newborns, countries around the world generally choose one of two approaches:

1. The "universal screening approach." Screen all pregnant people for GBS at 35-37 weeks (in the U.S. this has been changed to 36-37 weeks) and treat everyone who tests positive with appropriate antibiotics during labor. This is the method that is recommended by the World Health Organization and currently used in 60 countries including the U.S., Canada, Mexico, Brazil, Chile, Argentina, Uruguay, France, Germany, Spain, Australia, Portugal, Iran, Oman, the United Arab Emirates, and Japan (Le Doare et al. 2017).

2. The "other risk factor approach." Do not screen for GBS. Instead, treat laboring people with antibiotics if they have one or more of these other risk factors:

GBS in the urine at any point in pregnancy.

Previously gave birth to an infant with early GBS disease.

Preterm labor.

Fever during labor.

Water has been broken for more than 18 hours.

Note: The specific risk factors that are chosen may vary slightly from country to country. This method is currently used in 25 countries including the United Kingdom, Ireland, the Netherlands, Norway, Sweden, Finland, Iceland, Saudi Arabia, Tanzania, South Africa, India, Bangladesh, Thailand, the Philippines, and New Zealand (Le Doare et al. 2017).

Later in this article, we will discuss which approach is most supported by evidence-the universal screening approach, or the other risk factor approach. But first, let's describe the microbiome and how it works in the human body.

The microbiome is the ecosystem of trillions of microbes (bacteria, fungi, protozoa, and viruses) that live and co-exist with you in certain places in your body-such as your skin, gut (intestines, rectum), nose, mouth, and genital and urinary tracts.

The different types of bacteria that make up your microbiome can have good, neutral, or negative impacts on your body. The microbes that have good effects are called beneficial bacteria, or probiotics. Probiotics are like invisible workers that positively influence countless aspects of your body, including energy, digestion, brain activity (behavior and emotions), drug metabolism, the release of essential vitamins, protection against infection, and more ( Trinh et al. 2018).

Your microbiome gets its start before you are born. Researchers have found that fetuses swallow tiny amounts of maternal gut bacteria floating in the fetal amniotic fluid (i.e. the "waters" inside your amniotic sac). But the bulk of your microbiome is seeded at birth, when you are exposed for the first time to your birthing parent's genital tract and/or skin (Gensollen et al. 2016).

In fact, one reason that newborns born by vaginal birth tend to have better health outcomes in infancy and childhood is because a microbiome seeded by a vaginal birth tends to have more beneficial bacteria at a young age (when your immune system is developing) than a microbiome seeded by a Cesarean birth (Milani et al. 2017).

Some parents who give birth by Cesarean may attempt to replicate the microbiome received after a vaginal birth by wiping their baby's mouth, face, and skin with the birthing person's vaginal fluids, in a practice known as "vaginal seeding." This practice is controversial, and we will not cover it in this article, but you can learn more about it here.

Infant feeding methods also have a strong influence on the microbiome. Human milk contains antibodies, or immune properties, that fight bad bacteria and prevent it from finding a permanent home in the gut. Human milk also contains large amounts of oligosaccharides -complex sugars that feed beneficial bacteria. By boosting the beneficial bacteria, the oligosaccharides also positively influence a bodyfed newborn's immune system and their ability to fight infections (Milani et al. 2017).

The microbiome is constantly changing in the first three years of life as you have close contact with new people, places, animals, foods, and fluids. After three years, your microbiome stabilizes and the bulk of it will remain the same through adulthood, except for when you experience infections and/or have close contact with different types of bacteria (Gensollen et al. 2016).

Some people who are not carriers of GBS bacteria in childhood may become GBS positive later in life through close or intimate contact with other people. However, Group B Strep is not considered a sexually transmitted infection for two main reasons: 1) it's a naturally occurring bacteria present in many people who are not sexually active, 2) it rarely causes infection or problems unless you are a newborn, elderly, or immunosuppressed (Steer and Plumb, 2011).

Group B Strep can join your body's microbiome if you have close contact with someone else who carries GBS... just like how other bacteria may be introduced into your microbiome through close contact with others. There is no evidence that Group B Strep is spread by water, food, or surfaces (CDC, "About Group B Strep," 2022).

Right before a baby is born, the microbiome has not been seeded, and there is a window of opportunity for bad bacteria to gain a foothold in a fetus's body (Gensollen et al. 2016).

Fortunately, there are multiple ways that fetuses are protected from infection during pregnancy. One major protective factor is the chorioamnion, also known as the fetal membranes, or the "bag" or "sac" surrounding the waters. The membranes are an important barrier that prevent bacteria from getting into the uterus and fetus (Parry & Strauss 1998).

However, once the membranes rupture (also known as your "waters breaking"), there is now a potential pathway for infection to occur. Group B Strep bacteria, if present, can travel from the vagina up into the amniotic fluid and uterus, in what is called an ascending infection or vertical transmission. The fetus may swallow some of the GBS bacteria into their lungs and possibly experience early GBS disease (Puopolo et al. 2019).

Early onset GBS disease is defined as detecting GBS in the blood, cerebrospinal fluid, or lungs, along with the infant showing signs of clinical disease such as sepsis (bloodstream infection), meningitis, or pneumonia, during the first 6 days of life (Seale et al. 2014).

When a baby has early GBS disease, symptoms appear at birth or shortly after birth (Puopolo et al. 2019), and almost all babies (95%) will have symptoms within 48 hours (Nandruri et al. 2019). In a study of 148,000 infants born between 2000 and 2008, almost all of the 94 infants who developed early GBS disease were diagnosed within one hour after birth-which is why researchers believe that GBS disease usually begins before birth ( Tudela et al. 2012).

Newborns can also become carriers of GBS when it meets their skin, nose, and mouth as they travel down the birth canal during a vaginal birth. However, most of these infants stay healthy ( CDC 2010).

A meta-analysis combining data from many studies around the world estimated that in the year 2015, out of 140 million live births, about 205,000 infants had early GBS disease (Seale et al. 2017).

Researchers have studied GBS and found that if a birthing person who carries GBS is not treated with antibiotics during labor, the baby's risk of becoming a carrier of GBS is approximately 50% and the risk of early GBS disease is 1 to 2% ( Boyer & Gotoff 1985; CDC 2010; Feigin, Cherry et al. 2009). As noted earlier, being a carrier of GBS is not the same thing as having early GBS disease- most carrier infants stay healthy.

On the other hand, if the birthing person with GBS is treated with antibiotics during labor, the risk of their infant developing early GBS disease drops by 80%. So, for example, the risk could drop from 1% down to 0.2%. ( Ohlsson 2013)

In the U.S., the Centers for Disease Control (CDC) runs the Active Bacterial Core surveillance (ABCs), a program that tracks potentially invasive bacteria in a sample of ten states, covering a population of 45 million people.

In the early 1990s, before the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) recommended universal screening for GBS and treating it with IV antibiotics during labor, there were 1.8 cases of early GBS disease per 1,000 live births (ACOG 2019).

After the newer recommendations went into action, rates of early GBS disease in the U.S. dropped drastically. In the most recent data set, the ABCs program found that there are only 0.2 cases of early GBS disease per 1,000 live births (CDC, 2020).

In England, where the other risk factor approach is used to lower the risk of early GBS disease, the 2020 rate of early GBS disease was 0.53 per 1,000 live births, which is more than double the rate in the U.S. (UK Health Security Agency, 2021).

Researchers who study global rates of GBS disease reported that in 2015 there were 51,000 deaths of infants with early GBS in places with no access to health care facilities, 27,000 early GBS deaths in developing countries with some access to health facilities (a mix of areas with access to health care facilities and other areas without access), and 500 early GBS deaths in developed countries with reliable access to health facilities (Seale et al. 2017).

When stillbirths from GBS, early GBS disease, and late-onset GBS cases were combined, GBS was a leading cause of fetal/infant death around the world, causing more than 127,000 infant deaths and stillbirths each year. The burden of infant mortality from early GBS disease is born disparately by low-resource countries. The countries with the highest annual numbers of infant GBS disease deaths include India (13,000), Nigeria (8,000), Ethiopia (4,000), the Democratic Republic of the Congo (4,000), and Pakistan (3,000) (Seale et al. 2017).

In the year 2015, it was estimated that in-labor antibiotics prevented approximately 29,000 cases of early GBS disease and 3,000 early newborn deaths, mainly in high-income countries that have access to this approach. If in-labor antibiotics were available worldwide, it is estimated that another 83,000 cases of early GBS disease and 27,000 infant deaths could be prevented each year (Seale et al. 2017).

In the U.S., which is considered a high-resource country by researchers (despite the high number of perinatal care deserts), approximately 6.9% of full-term infants with early GBS disease will die from their infection. Death rates are higher (19.2%) in preterm infants with early GBS disease (Nanduri et al. 2019).

Although newborns in high-resource countries will most likely survive if they have early GBS disease, their illnesses usually require long, expensive stays in a NICU. During these NICU stays, infants receive invasive interventions to treat serious illness from GBS-caused pneumonia, sepsis, or meningitis.

In middle- to high-resource countries, up to 18% of infants who survive GBS meningitis end up with moderate to severe neurodevelopmental problems, including long-term cognitive, motor, vision, or hearing impairment. Rates of long-term neurological problems are likely much higher in low-resource parts of the world (Kohli-Lynch et al., 2017).

Very little is known about the long-term health risks of infants who have GBS with sepsis or pneumonia, but some may have long-term developmental problems as well (Kohli-Lynch et al., 2017).

The main risk factor for early GBS disease is when the birthing person is a carrier of GBS.

However, there are some other factors that increase the likelihood that a baby may have early GBS disease:

Being born preterm* has been linked with a higher risk of the baby having early GBS disease, possibly because a GBS uterine infection can lead to preterm birth in the first place (Puopolo et al. 2019).

A long time period (18-24 hours or longer) between water breaking and giving birth* (Boyer & Gotoff 1985; Velaphi et al. 2003; Heath et al. 2009).

Birthing person has a high temperature during labor (> 38 C or 100.4 F)* (Boyer & Gotoff 1985; Adair et al. 2003; Velaphi et al. 2003; Heath et al. 2009; Ying et al. 2019).

The waters broke before labor started, also known as premature rupture of membranes (Adair et al. 2003).

Infection of the membranes inside the uterus, also known as chorioamnionitis (Adair et al. 2003).

Having previously given birth to an infant with early GBS disease (a sign that there is heavy presence of GBS in the birthing person) (Puopolo et al. 2019).

Intrauterine monitoring during labor (Adair et al. 2003).

Membrane stripping or sweeping (Ying et al. 2019).

Identifying GBS in the urine at any point during pregnancy, which is a sign of a heavy presence of GBS (Carroll et al. 2016).

Giving birth for the first time (Carroll et al. 2016).

The items marked with an asterisk are some of the most important risk factors.

However, about 60% infants who develop early GBS disease have none of the risk factors on this bullet point list, except for the fact that the birthing person is a carrier of GBS ( Schrag et al. 2002).

In their most recent guidelines, ACOG recommends measuring GBS with a culture test at 36-37 weeks of pregnancy (not at 35 weeks, which used to be common).

To collect the sample for the culture test, a swab that resembles a long Q-tip will be used. The cotton tip should be inserted first into the vagina (not very far, only about 2 cm or ¾ inch), and then into the rectum (about 1 cm or ½ inch, through the anal sphincter). A speculum should not be used (ACOG 2019; ASM 2021).

Note: If GBS is identified in a urine culture during pregnancy, then the pregnant person is considered GBS positive and further culture screening does not need to take place (ACOG 2019).

After collecting the sample, the swab is placed in a special tube and sent to a laboratory for culture testing-where they see if the sample grows GBS bacteria. It takes about 48 hours to get the results back. People with severe allergies to penicillin should get additional results, called susceptibility testing, that describe whether the GBS they are carrying can be treated by alternative antibiotics (ACOG, 2019; ASM 2021).

When studying the accuracy of GBS tests, most researchers compare the culture results at 35-36 weeks (which used to be the standard practice, before it was changed to 36-37 weeks) to culture results from a sample collected during labor. A culture test during labor would be considered the "gold standard," but because it takes 48 hours to get results back, this method is not used in practice.

Because people can test positive for GBS consistently or temporarily (results can change, depending on how much or how little GBS is present in your gut), the goal is to get results within at least 5 weeks of giving birth-which should be a reliable sign of whether GBS will be present in your birth canal during labor (ACOG, 2019).

In one high-quality study (Young et al. 2011), researchers did the culture test twice for each birthing person- once at 35-36 weeks and once more during labor. They compared the 35-36-week results to results from the culture taken during labor.

Of all the pregnant people who screened negative for GBS at 35-36 weeks, 91% were still GBS-negative when the culture was done during labor. The other 9% became GBS positive. These 9% were "missed" GBS cases, meaning that they were carriers of GBS, but most (41 out of 42) did not receive antibiotics.

Of all the pregnant people who screened positive for GBS at 35-36 weeks, 84% were still GBS positive when the culture was taken during labor. However, 16% of the GBS-positive people became GBS-negative by the time they went into labor. These 16% received unnecessary antibiotics.

Antibiotics are medications that target and kill bacteria.

Most people today take the existence of antibiotics for granted. However, before clean water and antibiotics were widely available, bacterial infections caused massive amounts of human suffering (and continue to do so in low-resource areas).

For example, if you lived in the year 1900 in the U.S.:

The average life expectancy was 47 years old.

The leading causes of death were pneumonia, tuberculosis, and bacterial diarrhea, which (together with diptheria, another bacteria) caused one-third of all deaths, and 40% of these deaths were among children under the age of 5.

Most (90%) of children who caught meningitis died.

Strep throat could lead to scarlet fever, which could cause heart damage and heart failure.

Cesareans had a very high maternal mortality rate (sometimes as high as 80-90%), mainly because it was impossible to treat internal infections transmitted during the surgery.

Many people claim that antibiotics were "discovered" in the 1920s. However, that narrative is false. For millennia, humans have been identifying and using antimicrobial agents that occur naturally in nature. The first written description of antibiotics was in a papyrus from Egypt (dated 1500 BCE), where they described putting moldy bread on wounds. Researchers have found traces of tetracycline, an antibiotic, in ancient human skeletal remains in Sudan and Egypt. And antimicrobial agents are present in some herbs that have been used for thousands of years in Traditional Chinese Medicine. However, antibiotics were not mass produced and widely available until World War II (Hutching et al. 2019; Aminov 2010).

The story goes that in 1920, a British scientist named Alexander Fleming went away on vacation. When Fleming came back to his laboratory, he discovered he had accidentally left out a petri dish containing Staphylococcus aureus bacteria.

Something in the air-a Penicillium mold-had landed on the dish and emitted a substance that killed the bacteria everywhere it encountered it. Fleming named the substance penicillin, and over the next two decades, other researchers (including Ernst Boris Chain and Howard Florey) isolated and purified the compound-work for which the three of them won the Nobel Prize.

Eventually, penicillin was synthesized in factories and became a lifesaving medication during World War II. Infections and injuries that would have previously killed soldiers were now treatable.

Antibiotics also made their way into the delivery room. Fatal illnesses such as childbed fever, also known as puerperal sepsis (infection from group A streptococcus bacteria; transmitted from doctors' hands to the vagina and uterus) began to become a tale of the past (although puerperal sepsis continues to kill women in childbirth in low-resource areas of the world).

But antibiotics are not perfect. Certain antibiotics are only effective at killing specific bacteria. Some antibiotics (such as penicillin) have a narrower range of action, and others (such as vancomycin) can kill a broader swath of bacteria (these are called broad-spectrum antibiotics).

Antibiotics have side effects-they can cause rashes, nausea, vomiting, diarrhea, and decreased appetite. Broad-spectrum antibiotics have the strongest (worst) side effects, because they kill off more of the good bacteria in your microbiome. This creates an opening for other microbes to grow and flourish, such as C. diff, a bacteria resistant to many antibiotics that can cause life-threatening diarrhea, or Candidiasis, a fungus that causes yeast infections.

Some people may develop an allergy after being exposed to an antibiotic. However, most adults (80-90%) who say they have a history of penicillin allergy can tolerate penicillin. This is because the allergy can disappear over time. In other situations, the previous "allergy" symptoms were related to something else (like the original infection). Still, life-threatening allergic reactions, called anaphylaxis, can happen in some people who are at high risk for a severe reaction (ACOG 2019).

Bacteria can also evolve to resist the effects of an antibiotic. This is called antibiotic resistance. The more often antibiotics are used, the more likely it is the targeted bacteria will evolve their DNA to become resistant... and antibiotic-resistant bacteria then spreads. Doctors and scientists around the world have labeled antibiotic resistance a global threat. Some have predicted that by the year 2050, without urgent discovery of new antibiotics, ten million people per year will die from antibiotic resistant infections (Hutchings et al. 2019).

If a strain of bacteria in your body has NOT evolved to be resistant to a specific antibiotic, then that is called antibiotic susceptibility. For example, Group B Strep is almost always susceptible to penicillin ( CDC 2010; Melo et al. 2016; Nogacka et al. 2017).

In 1973, a researcher proposed giving pregnant people penicillin to prevent early GBS disease in infants ( Franciosi et al. 1973). So, researchers tried giving penicillin to pregnant people before labor, but this didn't work. Although penicillin temporarily lowered GBS levels, by the time labor started the GBS levels were back up again, showing that GBS grows back quickly once the antibiotic is removed from your system ( Gardner et al. 1979).

Next, researchers tried giving antibiotics during labor to those with GBS. In the late 1980's, three separate groups of researchers in the U.S., Spain, and Finland randomly assigned pregnant people with GBS to either receive IV antibiotics during labor (penicillin or ampicillin) or no antibiotics ( Boyer & Gotoff 1985; Tuppurainen and Hallman 1989; Matorras et al. 1991). Researchers combined the data from these 3 studies, with a total of 500 pregnant people, in a Cochrane review that was last revised in 2014.* The results showed that when participants with GBS had antibiotics during labor, the risk of their infants developing early GBS disease dropped by 83% ( Ohlsson & Shah 2013).

*Studies with this design-randomly assigning people with GBS to antibiotics or no antibiotics-are highly unlikely to ever happen again. Since we have evidence that antibiotics during labor can prevent early GBS disease in newborns (including large observational studies detailed below), most researchers would consider it unethical to withhold antibiotics for the sake of research. So, these studies from 1985, 1989, and 1991 are probably the last randomized, controlled trials we will ever see on this topic.

As the Cochrane reviewers noted, there were quite a few limitations to these 3 studies. In their summary, the reviewers said "There is no valid information from these three small, old, and biased trials to inform clinical practice." Health care institutions in some countries, such as the United Kingdom, hold the same viewpoint, and thus do not universally screen for GBS and treat with antibiotics during labor.

However, an alternative perspective would be that there is some valid information from these studies, along with some limitations to the evidence. Let's break this down more.

We cite Cochrane reviews often in our work here at Evidence Based Birth®. The Cochrane Collaboration is a highly respected, not-for-profit organization that conducts meta-analyses on different topics related to healthcare. A meta-analysis is a type of research study in which researchers pool statistics from previous studies into one larger study.

The Cochrane Pregnancy and Childbirth Group has a policy that they only do meta-analyses on randomized, controlled trials. So, the Cochrane review on GBS (published in 2009 and "updated" but essentially unchanged in 2014) only includes the three small randomized, controlled trials we mentioned above. They do not include other types of evidence, such as evidence from large observational studies where some people received antibiotics and others did not.

The researchers who wrote the Cochrane review on Group B Strep came to strong conclusions against the use of antibiotics for Group B Strep. After reviewing the three existing randomized, controlled trials on GBS, they stated, "It is remarkable that in North America the commonly implemented practice of intrapartum antibiotic prophylaxis to GBS colonized women has been so poorly studied."

It is true that these three studies had some major limitations. In fact, most studies published before 1996 suffered from poor quality reports of their findings. In the mid-1990's, researchers were very concerned about the widespread quality problem with clinical trial reports. So, in 1996, researchers from Canada and the U.S. came together and published the CONSORT guidelines for clinical trials.

CONSORT stands for the Consolidated Standards of Reporting Trials, and it is basically an evidence-based checklist of items that researchers must disclose in their article before they can report the results of their studies in most medical journals. Publishing of the CONSORT guidelines forced researchers to be transparent about their methods, and this greatly improved our ability to evaluate the quality of a clinical trial. The CONSORT guidelines were updated in 2001 and again in 2010. The 2010 version overrules the previous versions, but the biggest changes to clinical research happened after the first CONSORT guidelines were released in 1996.

The three studies that the Cochrane reviewers critique as being "invalid" were published in 1986, 1989, and 1990, before the CONSORT guidelines were developed. So, this partially explains why the written reports of these three studies are not up to today's standards.

Keeping in mind the information about the Cochrane reviews and the history of clinical trials, Table 1 shares two perspectives on the Cochrane review findings on giving antibiotics during labor for GBS.

Table 1: Cochrane Perspective vs. Alternative Perspective

In summary, although these studies had limitations (not uncommon for research published before 1996), there is also some valid information that we can use.

Although it would be best if we had modern, larger, randomized, controlled trials on antibiotics for Group B Strep, such trials will not be available given that antibiotics are already in routine use, and it could be considered unethical to withhold antibiotics. We also have newer evidence from large observational studies that we can use to look at the potential benefits and risks of antibiotics for GBS.

In 1996, after the original randomized trials were published on GBS, the Centers for Disease Control (CDC) in the U.S. initially recommended two ways to prevent early GBS disease: 1) the universal screening approach, or 2) the other risk factor approach. Because health care providers were choosing to use one or the other approach, scientists in the U.S. had a unique opportunity to study the effects of the two different methods.

In a study published in the New England Journal of Medicine ( Schrag et al. 2002), researchers used CDC lab results and chart reviews to look at 629,912 live births that took place in the U.S. between the years 1998-1999.The researchers randomly selected 5,144 of these births to study, in addition to all 314 infants who were born with early GBS disease. They used hospital records to label people as receiving either the universal screening approach (52%) or the other risk factor approach (48%).

The results? The universal screening approach worked better than the other risk factor approach at preventing early GBS disease. Overall, there were 0.5 infants born with GBS per every 1,000 births. People in both groups received antibiotics about 33% of the time. But people whose care providers used the universal screening approach had a 54% reduction in the risk of early GBS disease compared to people whose care providers used the other risk factor approach.
The findings from this landmark study convinced the CDC to revise their guidelines in 2002 and only recommend the universal screening approach.
In 2002-2003, researchers looked at 819,528 births in the U.S. to see whether the new guidelines had been put into practice. Like the previous study, the researchers picked a random sample of birthing people and infants to analyze, along with 254 infants who had early GBS disease. Between 1999 and 2002, use of the universal screening approach rose from about 50% to 85%, and use of antibiotics during labor rose from 27% to 32%.

This time around, there were 0.32 infants born with early GBS per every 1,000 birthing people (down from 0.5 cases per 1,000 only four years earlier). When researchers looked at term infants with early GBS disease, only 18% were born to pregnant people who were not screened. Most of the cases of early GBS disease in term infants (61%) happened in pregnant people who had been screened but tested negative for GBS (in other words, the test was a false negative). The researchers concluded that universal screening and antibiotic use cannot prevent all cases of early GBS disease. To lower GBS disease rates even more, a community would need easy access to vaccines against GBS ( Van Dyke et al. 2009).

In 2019, when researchers (Nanduri et al. 2019) published another analysis of early GBS disease in the U.S. and the effects of universal screening as prevention, they found that GBS disease continued to drop further (to 0.23 per 1,000 live births). When they analyzed the 1,277 infants who had early GBS disease over a 10-year period (2006 to 2015) in ten states, they found:

In 48% cases there was no medical reason for the providers to give antibiotics:

In most (83%) of these cases the screening test was negative for GBS (a false negative result).

In the remaining cases, the GBS screening tests results were unknown.

In 21.8% of cases there was an indication for antibiotics, but the antibiotics were not provided. For example, the birthing person had a history of GBS in the urine or had pre-term labor.

In 29.9% of cases the birthing person had received a recommended antibiotic, but the infant still developed early GBS disease:

Most (60.9%) of these birthing people did not receive at least 4 hours of antibiotics.

In some of the cases (39.1%) the appropriate antibiotic was started 4 or more hours before the birth.

In a meta-analysis (Russell et al. 2017) that combined data from 30 studies around the world with more than 20,000 pregnant people, researchers compared rates of early GBS disease in locations where: 1) there is no policy/method being used for preventing GBS disease, 2) there is a policy of universal screening for GBS and treatment with antibiotics during labor (with varying levels of implementation).

They found that in places where there is no policy for GBS disease prevention (common in many low-resource areas), the risk of early GBS disease if the birthing person is a GBS carrier is 1.1%. In settings where there was a policy of screening for GBS (and if antibiotics were given correctly 75% of the time), the risk of infants experiencing early GBS disease was 0.3%. These percentages line up with what was reported in the original randomized trials on Group B Strep prevention.

As we mentioned earlier, Nanduri et al. 2019 found that about 30% of cases of early GBS disease occurred even though the birthing person received antibiotics. But in most of those cases, the antibiotics were not given at least 4 hours before the baby's birth. Other researchers had similar findings-that 4 hours or more of antibiotics is the most effective way to prevent early GBS disease.

Fairlie et al. found that when penicillin or ampicillin is given to someone who is GBS positive more than 4 hours before birth, it is effective 89% of the time. In contrast, giving antibiotics 2-4 hours before birth was effective 38% of the time. Antibiotics given less than 2 hours before birth were also not as effective as antibiotics given more than 4 hours before the birth. When clindamycin (another antibiotic) was used in place of penicillin, it worked very poorly (it was only 22% effective). This is not surprising, because many strains of GBS are resistant to clindamycin.

In another study, researchers reviewed the medical records of 4,756 birthing people who received antibiotics during labor for GBS- 1,149 received antibiotics for less than 4 hours, and 3,633 receiving antibiotics for 4 or more hours. There was a higher rate of newborn sepsis in cases where less than 4 hours of antibiotics had been delivered, as compared to receiving 4 hours or more of antibiotics (1.4% versus 0.4%.) ( Turrentine et al., 2013).

In Uruguay, researchers followed 60 carriers of GBS at term who came to the hospital in early labor. They swabbed each person for GBS before antibiotics were started, and then again 2 and 4 hours after the first dose of penicillin was given. The researchers found that 72% of the participants were GBS positive before antibiotics were started, 47% were positive 2 hours after the first dose, and only 12% were positive for GBS 4 hours after the first dose. In all 60 newborns, the cord blood and amniotic fluid reached therapeutic levels of penicillin, even though 28% of the women gave birth before 4 hours. The maximum effect of the antibiotics was reached at 4 hours, just before the next dose was due ( Scasso et al. 2015).

Because it takes time for antibiotics to pass to the fetus at therapeutic levels and kill off GBS bacteria (Scasso et al. 2015), it makes sense that giving the first dose of antibiotics too late (for example, a few minutes before the birth) might not help to stop a GBS infection from growing in the fetus. Based on research evidence, ACOG recommends that antibiotics for GBS should be started at least 4 hours before birth. However, they also state that medically necessary interventions shouldn't be purposefully delayed just to get the 4 hours of antibiotics in before the birth of the baby. And although 4+ hours of antibiotics is ideal, 2 hours of antibiotics can still provide partial protection (ACOG 2019).

At the beginning of this article, we discussed the importance of the microbiome, and how it is seeded at birth. Unfortunately, antibiotics don't just affect the bad bacteria that they are targeting-they also impact other bacteria, including good bacteria, or probiotics.

When this Evidence Based Birth® article was first published in early 2014, there was no research on the microbiome effects of in-labor antibiotics for GBS. Since that time, researchers have published two meta-analyses and at least nine individual studies on the microbiota consequences of IV antibiotics during labor for Group B Strep.

We reviewed nine studies (Table 2) in which researchers enrolled infants who were exposed to antibiotics during labor (typically for GBS) as well as infants who were not exposed to IV antibiotics during labor. Most researchers studied the infant gut microbiome by collecting and analyzing bacteria in stool samples at different time points, ranging from two days of life to one year of age.

Overall, researchers found that receiving IV antibiotics during labor negatively impacts the infant's microbiome, at least temporarily. Eight of nine studies found that IV antibiotics during labor had at least a short-term effect on reducing beneficial bacteria and/or increasing levels of non-beneficial bacteria. Of the five studies that followed the infant microbiome over time, two found that the infant's microbiome had either recovered or mostly recovered by 4 to 8 weeks, while three other studies found important differences that persisted up to three months or a year later in some infants.

Perhaps the most important study on this topic, and the only study to follow infants for a year, was conducted by researchers in Canada (Azad et al. 2016). Infants could be included in the microbiome study if they had stool samples collected at three months and one year, and if they had complete information about antibiotic exposure during labor and infancy.

The 198 infants in this study were separated into four groups:

No antibiotic exposure during labor with vaginal birth (57%).

Antibiotic exposure with vaginal birth (21%).

Antibiotic exposure with elective Cesarean (9%).

Antibiotic exposure with unplanned Cesarean (13%).

Cefazolin was the antibiotic that was typically used during Cesareans, and penicillin was the antibiotic of choice for vaginal births. Researchers also measured the presence and duration of exclusive breastfeeding/chestfeeding.

The results showed that the infant microbiome was influenced by antibiotic exposure during labor, birth route (Cesarean or vaginal birth), and breastfeeding/chestfeeding. At three months, infants exposed to antibiotics during labor or birth had a decreased level of Bacteroidetes (a beneficial bacteria), as well as a decrease in the "richness" of their microbiome, regardless of whether they were exclusively breastfed/chestfed or not. The most severe deficiencies happened among infants born by Cesarean. Infants born by Cesarean also had higher levels of Clostridium, Enterococcus, and Streptococcus -potentially harmful bacteria.

At one year of age, most of these differences were gone, showing that antibiotics only have a short-term effect on the infant microbiome. However, some negative effects on the microbiome persisted in infants born by unplanned Cesarean who had not been breastfed/chestfed for at least 3 months. And other researchers caution that temporary changes in the microbiome during that first year could still have a negative long-term impact on the developing immune system (Zimmerman & Curtis 2019).

The changes in the microbiome seen in all these studies are consistent with what one would expect after administering IV antibiotics, like penicillin and ampicillin, that mainly act against gram-positive bacteria. Killing off gram-positive bacteria (like Group B Strep) can lead to an over-abundance of gram-negative bacteria. Also, some beneficial bacteria, like Bacteroidetes, are sensitive to penicillin and ampicillin, meaning that they are also killed off by the antibiotic.

In summary, it does appear that IV antibiotics during childbirth have a short-term negative effect on the infant's microbiome, but that this negative effect can be lessened by vaginal birth and breastfeeding/chestfeeding. Research is still needed to determine if there are any long-term immune effects associated with the temporary reduction in beneficial bacteria.

Parents who receive antibiotics and have a Cesarean, or those who choose not to breastfeed/chestfeed may need support from care providers in using other methods (such as donor human milk, probiotic supplementation, or formula with probiotics) to help their baby recover from any negative microbiome impact.

In clinical trials and in observational studies, giving antibiotics (penicillin or ampicillin) to GBS carriers during labor decreases the risk of early GBS disease by 83% (Ohlsson 2013; Russell et al. 2017).

Penicillin and ampicillin rapidly cross the placenta into the fetal circulation (at non-toxic levels) and can prevent GBS from growing in the fetus in most cases (ACOG 2019; Barber et al. 2008).

In a large observational study comparing both approaches, the universal approach (screening and treating all GBS-positive patients with appropriate antibiotics during labor) was associated with lower rates of early GBS disease than giving antibiotics based on other risk factors (Van Dyke et al. 2009).

Most researchers have found that antibiotic resistance has not been a problem with penicillin, the drug most commonly used to prevent early GBS disease (CDC 2010; Melo et al. 2016; Nogacka et al. 2017).

Although rare, severe allergic reactions in birthing people have been reported. In one study of more than 700,000 births in Texas, there were 19 cases of anaphylaxis- 5 due to penicillin and 6 due to cephalosporins, with zero deaths (Mulla et al. 2010). A meta-analysis of all studies published between 1985 to 2021 on severe anaphylaxis during pregnancy did not identify any maternal deaths due to an anaphylactic reaction to antibiotics (Simionescu et al. 2021).

IV antibiotics have a short-term negative effect on the infant's microbiome. Whether or not this translates into a long-term effect on the developing immune system is unknown. The antibiotic's negative effects on the microbiome can be lessened by breastfeeding/chestfeeding and vaginal birth.

Because antibiotics can kill off good bacteria as well as bad bacteria, antibiotics increase the risk of yeast infections, which thrive in the absence of good bacteria.

Yeast or fungal infections, known as Candidiasis, can harm the breastfeeding/chestfeeding relationship.

With a dual parent-infant yeast infection, the postpartum person may develop red/painful nipples, while their infant may experience thrush (inflamed, painful mouth).

In one study, 15% of people who received antibiotics in labor had postpartum yeast infections along with their baby, compared to 7% of those who did not have antibiotics (Dinsmoor et al. 2005).

Other potential harms have to do with side effects related to the antibiotic that is used (click on the link to see a comprehensive list of potential side effects for each antibiotic, but keep in mind that most of the serious risks are rare): penicillin, ampicillin, cefazolin, clindamycin, and vancomycin. See more information about clindamycin and vancomycin in the section below.

Antibiotics contribute to the medicalization of labor and birth because of the need for early hospital admission, IV insertion, and IV medications (RCOG 2017).

As mentioned earlier, most adults who say they have an allergy to penicillin are no longer allergic to penicillin. However, some people remain at high risk for severe allergic reactions. In their guidelines on GBS, ACOG (2019) provides a flow chart to help determine which antibiotic should be used for GBS in cases where there is a suspected penicillin allergy.

The strategy that ACOG recommends includes:

During a prenatal visit, the birthing person should describe any past allergic reaction to penicillin.

If their history indicates that they have a low risk of penicillin allergy, then they can receive cefazolin instead:

It used to be taught that 8-10% people with a penicillin allergy could be "cross-allergic" to cefazolin, but now we know that situation is less common (<1% to 4%). Most people who are allergic to penicillin can tolerate cefazolin.

Another option would be to undergo skin testing to determine if they have a true penicillin allergy.

If the history indicates that they are at high risk for a penicillin allergy:

The third trimester GBS culture should test for clindamycin susceptibility.

If the strain of GBS is susceptible to clindamycin, then clindamycin can be given.

If the strain of GBS is resistant to clindamycin, then vancomycin can be given.

Another option would be to undergo skin testing to determine if they have a true penicillin allergy.

People with an unknown risk of allergy to penicillin (for example, they aren't sure if they are allergic or not) can have skin testing, take cefazolin, or receive clindamycin or vancomycin (depending on the GBS culture results).

Erythromycin should never be used for GBS. Most strains of GBS are resistant to erythromycin, and erythromycin does not cross the placenta.

Note: Ampicillin is a type of penicillin-so if you're allergic to penicillin, you should not take ampicillin.

As you may have noticed from the ACOG guidelines, most people who have an allergy to penicillin can take cefazolin instead. One advantage to cefazolin is that (like penicillin) it crosses the placenta and reaches the fetal bloodstream. Also, it has a narrow range of action, is not as harmful to the microbiome as clindamycin and vancomycin, and can be given every 8 hours (instead of every 4 hours like penicillin).

If someone cannot take penicillin, ampicillin, or cefazolin, the two alternate options-clindamycin and vancomycin-have never been tested in clinical trials for the prevention of early GBS disease. Clindamycin faces high rates of drug resistance, barely reaches the fetal bloodstream, and should never be used unless the GBS strain is shown in culture testing to be susceptible to clindamycin.

Vancomycin, a broad-spectrum antibiotic, attacks many different types of bacteria. As a result, it has more frequent side effects, more serious side effects, and a larger impact on the microbiome. Also, overuse of vancomycin increases the risk that our communities will develop antibiotic resistance to vancomycin. Vancomycin's serious potential side effects means that there must be safety protocols in place, such as giving it slowly (over 1-2 hours), checking kidney function (via a blood test before the drug is given), and using weight-based dosing.

Weight-based dosing with vancomycin means that the dose given is based on the birthing person's weight:

When vancomycin is given without respect to the birthing person's weight (about 1 gram given every 12 hours), then it reaches the fetal bloodstream only 9% of the time.

A lower weight-based dose (15 mg per kg given every 12 hours) reaches the fetal bloodstream 33% of the time.

A higher weight-based dose (20 mg per kg every 8 hours) reaches the fetal bloodstream 83% of the time.

If vancomycin is being given at a dose > 1 gram, it may need to be administered even more slowly than usual (over at least 2 hours). Premedication with an antihistamine such as Benadryl may help prevent flushing and other uncomfortable side effects due to the vancomycin. Also, the Association of Ontario Midwives states that, "Due to the controlled conditions under which vancomycin is administered, home birth is not a feasible option for GBS-positive individuals who choose IAP and whose only choice of antibiotic is vancomycin."

Unfortunately, the American Academy of Pediatrics does not consider clindamycin or vancomycin to be "adequate" prevention of early GBS disease, which sometimes mean more newborn monitoring will be recommended. See the FAQ for more information about this dilemma.

Are there any other options?

As we've discussed earlier, one alternative to the universal approach is the "other risk factor approach." This is when you receive antibiotics based on other risk factors such as having a fever, or your water being broken for more than 18 hours.

Researchers have found that the percentage of birthing people who receive antibiotics is roughly the same whether you choose the universal screening approach or the other risk factor approach-about 30%. However, as already mentioned, evidence from large observational studies shows that the universal screening approach is more effective than giving antibiotics based on other risk factors.

Some countries have changed their policy to include GBS testing in their other risk factor approach, even though we do not have research yet on a combination approach (Le Doare et al. 2017). For example, birthing people might be treated with antibiotics if they are GBS positive PLUS they have fever or prolonged rupture of membranes. But in most cases of early GBS disease, the only risk factor is that the birthing person is a carrier of GBS. So, it's possible that the combination strategy (of requiring a positive GBS test plus one other risk factor) will not prevent most cases of early GBS disease in newborns.

Chlorhexidine is a topical disinfectant that kills bacteria on contact. It binds easily to the skin and mucous membranes. In the vagina, the anti-GBS effects of chlorhexidine last from 3 to 6 hours. Chlorhexidine has been shown to be safe, is easy to administer, and is inexpensive ( Goldenberg et al. 2006). Hibiclens is a brand formulation that includes chlorhexidine. Most of the research studies have used chlorhexidine; however, in the U.S., many providers can only access Hibiclens.

In a Cochrane review that was last updated in 2014 ( Ohlsson et al. 2014), researchers combined results from 4 randomized, controlled trials that compared vaginal chlorhexidine vs. a placebo or no treatment on the health outcomes of 1,125 infants born to parents who were GBS positive. The evidence from these studies was judged to be of very low quality using the GRADE system of evaluating clinical trials. The researchers removed a fifth trial that had been included in previous versions of the Cochrane review, because it did not include people with known positive GBS status. They also corrected a data mistake from the previous version.

The Cochrane reviewers found that chlorhexidine does not reduce the infants' risk of becoming a carrier of GBS. They also found no difference in early GBS disease rates among those who used the chlorhexidine and those who did not. There were no cases of infant deaths from GBS in either group. The chlorhexidine group had higher rates of stinging and irritation. The researchers called for a large clinical trial to test chlorhexidine for the prevention of early GBS disease.

Chlorhexidine could be beneficial for pregnant people living in low-resource areas where access to antibiotics is limited. In their review of the literature, Goldenberg et al. (2006) found two studies from low-resource countries ( Egypt and Malawi) where researchers administered chlorhexidine in the vagina every 4 hours during labor and then wiped the newborn with chlorhexidine shortly after birth. This is a lower level of evidence than the studies listed above, because neither of these were randomized, controlled trials. Instead, the researchers followed hospitals over a period of months when: 1) they did not use chlorhexidine, 2) they used chlorhexidine, and 3) they stopped using chlorhexidine.

In both studies, researchers found that when chlorhexidine was used in the vagina and wiped all over the newborn, there were immediate drops in newborn hospital admissions, newborn sepsis admissions, and newborn deaths due to infections. Unfortunately, researchers did not specifically count the cases of GBS disease, just the overall number of babies who had admissions for sepsis.

So, is chlorhexidine effective? Randomized, controlled trials show that in high-resource countries, applying chlorhexidine topically during labor does not reduce GBS carrier rates or early GBS disease. However, evidence from low-resource countries shows that chlorhexidine vaginal wipes PLUS newborn wipes may lower newborn sepsis rates in general. And some researchers have proposed that in low-resource areas, applying chlorhexidine to the umbilical cord stump (after the baby is born) could prevent GBS-related blood infections after birth (Islam et al. 2016).

Chlorhexidine might be better than nothing, but it does not prevent the rise of GBS in the baby's blood and amniotic fluid unless it is given before the birthing person's water breaks and repeated before the effect wears off. In contrast, IV antibiotics quickly get into the fetal blood circulation to prevent or stop GBS disease from growing in the body.

Garlic has antibacterial properties, and some websites recommend putting garlic in the vagina to eliminate GBS before the GBS test. However, there are only two laboratory-based studies on this subject:

One group of researchers (Cutler et al. 2009) put garlic extract and GBS in a petri dish together. They found that the garlic was able to kill the GBS within about 3 hours.

Another group of researchers (Torres et al. 2021) tested compounds from garlic and found that 4 of the compounds inhibited the growth of GBS in a petri dish.

Although garlic may seem like a promising natural treatment, it's important to understand that this treatment has never been tested in humans (a letter to the editor written by Cohain in 2009 is sometimes cited as a study, but it is not a research study).

If garlic has any anti-GBS effect, it's likely only temporary. Back in the 1970s, when researchers tried giving penicillin during pregnancy (instead of during labor), they found it temporarily lowered levels of GBS, but levels almost always went back up by the time someone went into labor. So, by temporarily using garlic, this could help you get a negative test result, but the effect may wear off very quickly and the GBS could grow back.

There is no other info on the possible benefits and risks of short-term or long-term garlic use in the vagina. It's possible that garlic insertion in the vagina could have unexpected effects like premature rupture of membranes or increase other bacteria- even GBS- due to destruction of good bacteria. Until we have more research on potential benefits and harms, there are a lot of unknowns related to this treatment.

Researchers have been working to develop a GBS vaccine for multiple reasons:

In-labor antibiotics do not prevent GBS infection 100% of the time.

In-labor antibiotics have side effects and can negatively impact the microbiome.

In-labor antibiotics do not prevent other GBS diseases, such as preterm labor, stillbirth, or late-onset GBS disease in newborns.

Pregnant people in low-resource parts of the world have difficulty accessing GBS testing and antibiotics during labor.

In an analysis published in 2017, Seale et al. predicted that, with a GBS vaccine that works 80% of the time and is administered to more than half of pregnant people in the world, we could prevent 23,000 stillbirths, 127,000 cases of early GBS disease in infants, and 37,000 infant deaths each year. They also calculated that vaccinating half of all pregnant people worldwide would be more effective at preventing disease and death than carrying out GBS screening and providing in-labor antibiotics to more than 50% of pregnant people.

There have been at least five pharmaceutical companies involved in developing GBS vaccines: Pfizer, GlaxoSmithKline (GSK) which acquired Novartis, Biovac, and Minervax. Most of the vaccines are in earlier phases including discovery, preclinical, and phase 1 testing. The Novartis/GSK GBS vaccine candidate has completed phase 2 safety testing in pregnant people.

In a 2020 study on the experimental Novartis/GSK vaccine for GBS (Swamy et al.), researchers carried out a randomized, placebo-controlled safety study in the U.S. They recruited healthy pregnant people between 24 and 34 weeks of pregnancy. All the participants received standard GBS testing and antibiotics during labor for GBS positive status-and 37% of the sample was positive for GBS.

Out of the 75 participants, 49 received one dose of the GBS vaccine and 26 received a placebo. The researchers followed the participants through the rest of pregnancy, birth, and up to 6 months postpartum. To measure the antibody response, they collected blood samples from the pregnant people on day 1 and 31 after vaccination, the day of giving birth, and postpartum days 42 and 90. They also collected infant cord blood samples at birth and infant blood samples on days 42 and 90.

The most common side effects were injection site pain (50% in vaccine group and 31% in the placebo group) and fatigue (38% of the vaccine group and 23% of the placebo group). There were zero vaccine-related serious adverse events in the study, and no differences in pregnancy/birth outcomes between the two groups. At six months of age, they performed developmental assessments on the infants and found no differences between groups with cognitive, communication, fine motor, and gross motor skills.

On day 31 after receiving the vaccine, the vaccine group had an immune response that was 13-23 times higher than in the placebo group. Antibodies transferred to the fetus through the placenta, and antibodies were detected in the infant's blood from birth through 90 days of follow-up. The vaccinated group also had high levels of antibodies in human milk samples.

Currently, public health experts are optimistic about the possible positive impact that GBS vaccines could have around the world:

"An effective maternal GBS vaccine offers an all-encompassing approach to reducing GBS disease, and, as vaccine strategies can achieve high coverage in even the most challenging settings, it is likely to be a more equitable intervention than intrapartum antibiotic prophylaxis. Maternal GBS vaccination has the potential to reduce this disease burden worldwide, within the next generation and including the poorest families" (Seale et al. 2017).

In theory, taking probiotics in pregnancy should help lower the odds that you will test positive for GBS in the third trimester. This is because beneficial bacteria, such as Lactobacillus, make the vagina more acidic, which inhibits growth of GBS (Hanson et al. 2022).

In a meta-analysis published in 2022, Hanson et al. reviewed six studies (3 randomized trials, 2 observational studies, and 1 semi-randomized trial) that examined whether oral probiotics (primarily Lactobacillus) can lower rates of GBS in pregnancy.

The authors determined that probiotics had a moderate effect on reducing rates of testing positive for GBS in pregnancy. However, five of the six studies in this meta-analysis were at high risk for bias, meaning that we can't have confidence in their results. For example, in one study, pregnant people were put into probiotic and control groups based on whether they were sick and wanted to take probiotics or not (leading to two very different groups), and no baseline measurement of GBS was collected. Another study also did not measure GBS before the probiotics were started, and it had to be shut down early because the probiotics expired.

Hanson et al. (2023) went on to carry out their own high-quality randomized trial, which was supposed to address some of the problems in the earlier research. Their study included these strategies:

They enrolled 109 healthy pregnant people, with the knowledge that at least 80 would need to complete the study to find a difference between probiotic and placebo.

The participants were randomly assigned to either receive 1) highly potent capsules with Lactobacillus and other probiotics (on the U.S. market as "Florajen Digestion") or 2) placebo capsules. Both groups started the pills at 28 weeks of pregnancy and continued until labor.

Baseline swabs for GBS were collected at 28 weeks and again at 36 weeks.

The participants and study staff were not allowed to know which group each person was in in, and the probiotic and placebo pills were identical in appearance and taste-so it was a true double-blind study.

Adherence was measured with the use of special pill bottles that track how often the pill bottle was opened.

Probiotics were kept refrigerated and had frequency potency testing.

Participants received daily reminders to take their pills.

GI symptoms were measured by questionnaire at baseline, 28 weeks, and 36 weeks.

Yogurt ingestion, sexual activity, and vaginal cleansing practices were measured by questionnaire at baseline and 36 weeks.

In the end, 83 people completed the entire study protocol. The results showed that the probiotic group had fewer GI symptoms (per questionnaire) at 36 weeks compared to the placebo group. However, there was no difference in rates of testing positive for GBS at 36 weeks. The pill bottle caps showed that both groups took their assigned pills only about 51-60% of the time. There were no adverse health outcomes in either group.

In summary, the research on probiotics to lower the risk of testing positive for GBS is not very compelling. But no study has found bad side effects related to taking probiotics for GBS prevention, and at least three trials found that oral probiotics can lessen GI symptoms in pregnancy (Hanson et al. 2022; Hanson et al. 2023). So, although taking oral probiotics might not lower your chances of carrying GBS, it doesn't seem to hurt, and it might help with other symptoms of pregnancy.

Recently, researchers have begun to explore the possibility of applying human milk onto the vagina to suppress GBS. One of the main ingredients in human milk is oligosaccharides, also known as human milk oligosaccharides, or HMOs. This key component of human milk was first identified in the early 1930s, when scientists were trying to understand why survival rates were higher when infants were fed with human milk rather than formula based on cow's milk (Bode 2012).

There are more than 100 types of HMOs found in human milk, and HMOs make up 8% to 20% of each ounce. HMOs are carbohydrates that are more complex than simple sugars, but less complex than starches. Scientists are still trying to understand the effects of HMOs, but so far HMOs have been shown to act as prebiotics (feed good bacteria in the gut), block bad bacteria from finding a home in the gut, positively impact the immune system, and provide nutrients for brain development, among other benefits (Bode 2012).

Farm animals (such as cows and goats) produce very few oligosaccharides, at levels that are 100 to 1,000 times less than human milk, and there is no other natural source where HMOs can be found. To mimic the effects of HMOs, non-HMOs are currently added to some infant formulas. Researchers have described short-term benefits of providing non-HMOs to formula-fed infants, but we still need research on long-term benefits and risks (Bode 2012).

Earlier in this article, we discussed how feeding an infant human milk can help lessen the negative effects of antibiotics on the newborn microbiome. However, recent research has been published that suggests topical use of HMOs could be a potential pathway for preventing or treating GBS during pregnancy.

In 2017, three different research teams found that HMOs could inhibit the growth of GBS in petri dishes (Lyon & Doran 2022). Then in 2022, researchers found that topical use of HMOs can inhibit GBS in the vaginas of laboratory mice. They also found that the topical HMO treatment did not disturb the rest of the vaginal microbiome in mice (Mejia et al. 2022). Human research has not yet been conducted on this potential use of HMOs.

In their commentary on Mejia et al.'s study, Lyon & Doran (2022) wrote, "It will be interesting to see how the field of anti-GBS HMO activity will evolve in the coming years and how in vivo models will continue to explore this promising therapeutic agent for improved maternal and neonatal health."

A few websites mention colloidal silver as a remedy for preventing GBS infection. Although silver has anti-bacterial properties, no research studies have ever looked at the safety of colloidal silver in pregnancy.

In 1999, the Federal Drug Administration in the U.S. stated that colloidal silver is not safe or effective for any condition, and other researchers have reported serious toxicity and health risks.

Online misinformation about colloidal silver is common. For a peer-reviewed article for consumers with facts about colloidal silver, you can read this Healthline article.

There have been at least two studies showing that culture results after self-swabbing for Group B Strep can be nearly as accurate as letting a health care worker collect the swab. As a result, guidelines from ACOG in the U.S. mention that pregnant people can collect their own specimens after receiving instruction.

In one study on this topic, Price et al. (2006) studied GBS testing among a diverse group of pregnant people in Canada. Most of the people they approached (86%) agreed to participate, showing that collecting a self-swab of the vagina and rectum (through the anal sphincter) was acceptable. The participants were given written instructions and a diagram showing how the swab was done. All the participants did the self-swab and had a swab collected by health care workers-but they were randomly assigned as to which swab was collected first. In the end, the culture test from swabs collected by health care workers was slightly more sensitive (96.9% vs. 87.5%), but the results were acceptable in both groups.

A few years later, Arya et al. (2008) carried out a similar study in Ireland. Everyone self-collected a vaginal-rectal swab and had a health care worker collect a vaginal-rectal swab (but they were not randomly assigned as to which would be collected first). The sensitivity was acceptable for both swabs, but it was higher for the clinician-collected swab (94.3% vs. 84.3%). Only 29% of participants preferred the self-collection, while 43% preferred the health care worker collection, and 28% had no preference.

Next, researchers from Hong Kong (Seto et al. 2019) found that pregnant people there may be hesitant to collect their own sample, leading to less accurate results. In this study, pregnant participants were asked to self-swab and be swabbed by health care workers-they were randomized as to which swab happened first. About two-thirds of those who were approached agreed to be in the study. Everyone watched a video on how to collect the sample-instructions included inserting a cotton tip swab 2 cm into the vagina and another swab 1 cm through the anal sphincter. The results showed 97.6% sensitivity for the swabs collected by health care workers, but only 61.4% sensitivity for the self-collected swabs. The researchers concluded that cultural factors may make some groups less inclined to perform an accurate self-screening test.

To sum up the research on this topic, self-swabbing can be a good option for people who prefer to collect the sample themselves. But other people may prefer (and be more comfortable with) a health care worker collecting the sample for them.

Processing a GBS culture takes at least 1 to 2 days, which means the sample must be collected before labor begins-this is why testing is performed at 36-37 weeks of pregnancy.

Unfortunately, because GBS levels can increase (be undetectable at first, but then increase and populate the vagina/rectum) or decrease (be detectable at first, but then retreat farther back into the intestines and no longer populate the vagina/rectum), this means someone who tests positive at 36 weeks might not be positive during labor at around 40 weeks, and vice versa.

If a faster, reliable test was available, then testing could be done during labor- thus identifying and treating only those whose birth canal is populated with GBS while giving birth.

In theory, this approach would result in fewer missed cases of GBS (for those who were negative at 36-37 weeks, but positive during labor), as well as less use of unnecessary antibiotics (for those who were positive at 36-37 weeks, but negative during labor).

When we first published this Evidence Based Birth® Signature Article in 2014, it seemed like rapid GBS tests might be coming soon. However, subsequent research results revealed that rapid GBS tests are unlikely to be common for the following reasons:

When clinicians use rapid tests in real life situations (as opposed to in a clinical trial, where circumstances are under strict control), rapid GBS tests are not as sensitive/accurate as culture tests (Mueller et al. 2014).

Even the most "rapid" rapid tests still require 1.5 to 2 hours to process, which is not helpful if labor is moving quickly (ASM 2021; Mueller et al. 2014).

Research is conflicting on whether rapid tests lower the rate of unnecessary antibiotics (Daniels et al. 2022; Poncelet-Jasserand et al. 2013).

Rapid tests for GBS cannot screen for antibiotic susceptibility in people with allergies to penicillin (ASM 2021).

Relying on a rapid test strategy requires a laboratory that is open and running 24 hours/day, which is not available in some hospitals (ACOG 2019).

However, rapid tests might be an option with preterm labor, or for situations where someone wasn't tested or doesn't have culture results back yet. For this reason, some hospitals keep a supply of rapid tests for GBS (ASM 2021).

Not necessarily. If you use the antibiotics, you will have an IV placed, but it only takes a limited time for the antibiotics to run in. Each antibiotic is slightly different, but penicillin and ampicillin are usually infused over 15 minutes and given every 4 hours until birth, which for many people is only once or twice. For people with penicillin allergies, cefazolin is usually infused over 30 minutes and is given every 8 hours, clindamycin is infused over 10-60 minutes and given every 8 hours, and vancomycin is infused over at least 1 to 2 hours and given every 8 or 12 hours depending on the dose.

Some people may wonder why the doses need to be repeated. Evidence shows that as long as someone is in labor, the doses are repeated because the GBS-suppressing effect can wear off over time (ACOG 2019).

When the IV is running, it should not limit positioning, walking, or even laboring in water. For the hours in between, you can ask for the IV to be "hep-locked" or "saline-locked" and detached, so that you are free from the IV pole.

For more information about saline locks, please read our EBB article about saline locks during labor here.

Researchers are quite certain that infants usually catch early GBS disease before they are born-likely from GBS in the amniotic fluid. As mentioned earlier, almost all infants with early GBS infection show symptoms within an hour after birth.

Late-onset GBS disease usually starts between the age of 7 days and 3 months old. Treatment with antibiotics during labor does not prevent late-onset GBS disease in infants (ACOG 2019). Infants can catch late-onset GBS disease from the hospital (nursery, hands of hospital staff and family members) or the community. This is one reason handwashing is so important during the newborn period (Kliegman et al. 2011).
We have heard of this practice happening in the U.S., but we have not seen anything published about it in either the clinical guidelines or in research. Perhaps these care providers are testing their clients early to get an idea as to whether you are at higher risk for pre-term birth. However, GBS is the cause of only 1-2% of pre-term births. And any preventive treatment of GBS during pregnancy is temporary, since the GBS almost always grows back in the intestines once the antibiotics are stopped. However, if you have a UTI, and the urine culture grows GBS bacteria, then you do need to be treated with antibiotics to eliminate the GBS from your urinary tract.
If a baby is born at 35 weeks or later, guidelines from the AAP (Puopolo et al. 2019) describe three different approaches that health care workers might use:

1. Risk assessment by categories: There are different versions of this approach used around the world-see the AAP guidelines for a sample flowchart. If the birthing person carries GBS and received penicillin, ampicillin, or cefazolin 4 or more hours before birth, then the infant is labeled as having "adequate" early GBS disease prevention. On the other hand, if the birthing person carries GBS, and they received any other antibiotic, or antibiotics were given less than 4 hours before birth, then the infant would be considered as having "inadequate" prevention, and observation, blood cultures, or antibiotics may be prescribed, depending on the category that the infant falls under. A major drawback to this approach is that it results in interventions with many low-risk infants.

2. Neonatal Early-Onset Sepsis Calculator: Information about the birth, GBS status, and infant's health condition are entered into an evidence-based calculator developed through large, high-quality research studies. The calculator suggests different courses of action based on each infant's individual score. The calculator is free and publicly accessible here: https://neonatalsepsiscalculator.kaiserpermanente.org/ One benefit of this calculator is that it determines risk based on all kinds of infections, not just GBS.

3. Risk assessment based on newborn's health condition: Infants who appear well at birth do not receive any special tests or interventions. If the infant is well, but there was inadequate prevention of GBS or the birthing person had a fever during labor, then the infant should be checked frequently over the next 36-48 hours. Infants that appear sick at birth or develop signs of sickness over the first 48 hours after birth should have blood cultures drawn and be treated right away with antibiotics.

The AAP states that preterm infants born before 35 weeks 0 days gestation are at high risk for early infection from all causes, and health care providers should base their management on the circumstances of the preterm birth (for example, management of the infant would differ if the preterm birth was caused by a pregnant person's infection vs. preeclampsia).

It's important that parents educate themselves about what normal newborn behavior and appearance, as well as the warning signs of illness. The Association of Ontario Midwives has an excellent handout that includes all this information in a printer-friendly format: https://www.ontariomidwives.ca/gbs

Contact your provider if your newborn infant has signs of early GBS disease. The American Academy of Pediatrics (Puopolo et al. 2019) and Association of Ontario Midwives list the following symptoms:

Fast heart rate (for example, more than 160 beats per minute).

Fast breathing (for example, more than 60 breaths every minute, with the fast breathing lasting more than 10 minutes)

Lethargy (unable to wake baby to feed)

Limp and not interacting with caregiver when awake

Fever of 38 degrees C (100.4 F) or higher

Poor feeding

Irritability

High-pitched crying, or crying all the time

Grunting or nasal flaring

Baby's skin pulls in sharply around ribs or base of throat when breathing in

Repeated, projectile vomiting

Temperature instability

Bulging soft spots on the head

Brick dust color in baby's diaper more than 3 days after birth

No wet diaper in 24 hours

Any other worries about the baby's health

The Association of Ontario Midwives recommends calling 911 and your provider if your baby's skin color changes to blue, grey, or pale (although temporary blue hands and/or feet can be normal in the first few days of life) or their breathing stops for more than 10 seconds.

In the U.S., researchers have reported disparities with African American birthing people having higher rates of GBS positive tests, and higher rates of GBS disease in newborns (Nanduri et al. 2019). The 2022 Clinical Practice Guidelines from the Association of Ontario Midwives report that Black pregnant people may be more likely to convert from GBS negative to GBS positive due to systematic health disparities or inequitable delivery of antibiotics, but overall, these disparities are not widely researched nor well understood.

The American College of Obstetrics and Gynecology lists "maternal black race" among their list of risk factors for infants developing GBS disease. However, the Human Genome Project confirmed in 2003 that humans are 99.9% genetically identical and there are often more biological differences found within a single race, than found between people of different races (ACOG 2019, Duello et al. 2021). Geneticists have described race as a social construct, not a scientific one, and it may be challenging to determine societal expectations of "race" means for patients with any historically mixed ancestry. Experts in racial health disparities such as Dr. Joia Crear-Perry, OB-GYN, and Founder of the National Birth Equity Collaborative often clarify with the explanation:

"Race isn't the risk factor - racism is."

Research shows that as result of racism (including racial weathering and chronic stress), Black, Brown, and Indigenous communities experience higher rates of hypertension and labor complications, preterm labor, Cesarean rates, low birth weight babies, and lower rates of breastfeeding/chestfeeding (Geronimus et al. 2006; Larrabee Sonderlund et al. 2021). More specific and more measurable than "black race," some of these factors put infants at higher risk of developing GBS disease if exposed to GBS. Racial weathering also puts birthing people at risk of early cellular aging and a weakened immune system, making them vulnerable to allergies and imbalance in the microbiome gut bacteria (Carter et al. 2019). This puts them at risk of both becoming GBS positive and having a possible sensitivity or reaction to the antibiotics used to treat GBS.

Communities that experience discrimination in health care - for any reason - may also face real-time challenges from certain providers (whether the provider is aware or not), such as delays in care, less monitoring or less attentive monitoring, microaggressions, false beliefs about the patient, or unequal delivery of procedures and tests (Miller and Peck 2019, Hoffman et al. 2016, Smedley et al. 2003). Structural inequities may show up in low-resource areas where health centers face shortages of IV antibiotics, chronic understaffing and overworked providers, poor basic infrastructure or lack of access to laboratories for culture testing - all systemic factors that interrupt patients' access to care.

For any birthing person with multiple layers of risk factors, prevention and extra wrap-around care and attentiveness can be lifesaving. Evidence-based preventive health options such as probiotic supplementation can be discussed early on with birthing people and families of color. Extended families, doulas, and community advocates can be trained on the signs and symptoms of GBS disease and sepsis (infection) in newborns and how to use the Neonatal Early-Onset Sepsis Calculator determine the likelihood of illness. This can be a helpful resource to support their case, especially if they feel a provider is not listening or acting urgently enough to treat their child. Parents and health care workers should also be aware that low oxygen can look different on darker skin (more grayish or whitish rather than blue), and that pulse oximeters are more likely to have inaccurate results in infants with darker skin tones (Vesoulis et al. 2022).

In 2018, the U.S. Centers for Disease Control and Prevention transferred stewardship of GBS prevention guidelines to the American Congress of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics (AAP), and the American Society of Microbiology.

The 2019 ACOG recommendations (reaffirmed in 2022 and endorsed by the AAP) include:

All pregnant people should be tested for GBS between 36 weeks 0 days and 37 weeks 6 days.

Everyone who is positive for GBS should have appropriate IV antibiotics during birth unless they are giving birth by pre-labor Cesarean and the membranes have not yet ruptured.

The antibiotic of choice is IV penicillin, and IV ampicillin is an appropriate alternative.

For people with a reported allergy to penicillin, if they are at low risk for an anaphylactic allergic reaction, then IV cefazolin is recommended.

For people with an allergy to penicillin who are at high risk for anaphylaxis, then clindamycin should only be used if laboratory testing shows that their GBS strain is susceptible to clindamycin.

Testing for a penicillin allergy is also appropriate for people who have history of penicillin allergy, as many people with childhood reactions will no longer be sensitive/allergic to penicillin later in life.

If someone has a high-risk allergy to penicillin, and their GBS strain is resistant to clindamycin, then IV vancomycin is the only other alternative-strict weight-based dosing and safe medication delivery measures (detailed inside the guidelines) should be followed.

Health care staff should not delay or withhold necessary medical interventions (rupture of membranes, synthetic oxytocin, membrane sweeping, Foley cervical ripening, vaginal exams, intrauterine monitoring, or water immersion during labor) just because someone is GBS positive and/or the health care worker wants to give the recommended 4 hours of IV antibiotics before the delivery.

The 2019 AAP guidelines of how to manage infants at risk for GBS disease were mentioned in the section above and can be found here.

Detailed laboratory testing guidelines can be accessed from the American Society for Microbiology here:

They recommend that a single swab should be used to obtain a specimen first from the vagina (inserting it 2 cm), then from the rectum (inserting it 1 cm through the anal sphincter), without using a speculum.

Antibiotic susceptibility testing should be carried out on samples from patients with severe penicillin allergies.

The United Kingdom National Screening Committee states that pregnant people in the U.K. should not be screened for GBS. Screening for GBS in pregnancy is not covered by the National Health Service (NHS). However, some pregnant people choose to be screened for GBS outside of the NHS.

In general, practitioners in the U.K. follow the other risk factor approach. This includes giving antibiotics during labor to anyone with fever, prolonged rupture of membranes >18 hours, GBS in urine at any time during pregnancy, preterm labor, or a prior infant with GBS. As a result, some people who would have tested negative for GBS receive antibiotics directed at GBS. In the U.K., the rate of early GBS infections is 0.53 per 1,000 births, which is higher than the rate of 0.2 per 1,000 births in the U.S.

The Royal College of Obstetricians does not recommend routine screening for GBS during pregnancy. However, they do state that in-labor antibiotics could be considered if the birthing person seeks GBS testing outside the NHS and tests positive, or if the birthing person has any of the other risk factors listed above.

There is controversy in the U.K. over the lack of access to GBS testing within the National Health Service. Group B Strep Support is an independent charity that advocates for families to have access to GBS screening in the U.K. They offer a support teleline, leaflets and publications, a private Facebook community, and links to order GBS tests online.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends offering GBS screening to all pregnant people at 35 to 37 weeks and providing those who test positive (as well as anyone with an infant previously infected or a positive urine culture) with the appropriate antibiotics during labor.

The Association of Ontario Midwives recommends GBS screening and has many resources including thorough evidence-based practice guidelines, a GBS app for midwives, sample protocols, and handouts for parents on GBS in pregnancy and normal newborn behavior vs. signs of illness. The AOM's 2022 practice recommendations include:

Offer all midwife clients screening for GBS at 35 to 37 weeks; clients may be offered instruction on how to do the swab themselves.

Discuss the benefits and risks of penicillin allergy testing with clients who have an uncertain allergy.

Discuss the benefits and risks of two approaches: 1) screening for GBS at 35-37 weeks and having antibiotics during labor or 2) screening for GBS at 35-37 weeks but only having antibiotics in labor if an additional risk factor arises.

Group B Strep is a normal part of the microbiome bacteria for some pregnant people, but it can cause early GBS disease (a serious illness) in a minority of newborns, because of their immature immune system. Researchers have found that if a pregnant person who carries GBS is not treated with specific antibiotics during labor (penicillin, ampicillin, or cefazolin), then there is a 1 to 2% chance their infant will develop early GBS disease.

There has been a global debate as to whether we should focus on preventing early GBS disease vs. preventing the harms of antibiotics. In places where preventing more cases of early GBS disease is the priority, people are typically screened for GBS at 36 to 37 weeks of pregnancy and then, if positive, provided antibiotics during labor ("universal screening approach"). If appropriate antibiotics are given 4 hours or more before birth, then the risk of early GBS disease goes down to about 0.2%.

In places where preventing the harms of antibiotics is the priority, people are not screened for GBS during pregnancy and only given antibiotics during labor if other risk factors occur ("other risk factor approach"). Although antibiotic usage rates are similar with the universal screening approach or the other risk factor approach, rates of early GBS disease are higher with the other risk factor approach (0.5% vs. 0.2%). An excellent informed consent handout that describes the benefits and risks of both approaches is available at the Association of Ontario Midwives' website here: https://www.ontariomidwives.ca/gbs.

Although the universal approach is the most effective approach, it is not perfect, and it cannot eliminate all cases of early GBS disease. Also, the universal screening approach is only available where there is easy access to laboratory testing and intravenous antibiotics. In low-resource places where no policy at all is used to prevent GBS disease (neither the universal approach nor the other risk factor approach), GBS disparately causes serious newborn illness and death.

Eventually, the most effective way of preventing GBS disease in infants would be access to a safe and effective vaccine against GBS for pregnancy. One GBS vaccine has shown promising results in phase II testing. Other alternatives to antibiotics have either not been shown to be effective against GBS disease or have not been sufficiently studied. For example, research from randomized trials does not support the theory that topical chlorhexidine (sometimes called Hibiclens) prevents early GBS disease. Topical insertion of garlic into the vagina has also been mentioned as a possible treatment-but has not been studied in pregnant people. Early onset GBS disease usually begins when GBS gains access to the amniotic fluid and gets into the fetus' lungs during labor, so it's unlikely that topical applications can prevent cases of GBS disease in newborns.

Regardless of what method of GBS prevention is used, parents should educate themselves on the warning signs of newborn sickness in case they need to seek emergency medical care. The Association of Ontario Midwives has an excellent handout on normal newborn behavior that includes a list of warning signs to seek emergency medical attention. You can access their handout in different languages here: https://www.ontariomidwives.ca/gbs

Regardless of which strategy is used (universal screening vs. other risk factor approach), about one-third of people in high-resource countries are given IV antibiotics during birth. These antibiotics have the temporary side effect of negatively impacting the infant microbiome. If you receive IV antibiotics, there might be an increased need for probiotic supplementation for your infant after birth if you:

Cannot or choose not to feed infant with human milk.

Give birth by Cesarean.

Preterm birth or NICU admission.

Have a high risk of penicillin allergy and thus receive a broad-spectrum antibiotic (clindamycin or vancomycin) that has a stronger impact on the microbiome and is less likely to prevent GBS disease.

On the other hand, parents might have increased concern about GBS disease if they have:

Culture results that show they are a GBS carrier.

Preterm labor.

Prolonged rupture of membranes.

Fever during labor.

History of urinary tract infections with GBS or a prior infant with GBS disease.

Improper culture testing at 36-37 weeks (an inaccurate test is more likely to occur if the Q-tip did not enter through the anal sphincter).

We encourage parents who face decisions around GBS testing and antibiotics to have open conversations with their providers about the benefits and risks of their options. The truth is, there are trade-offs to every decision. With solid information and access to resources, we believe each family has the power to make the decision that is best for their unique situation.

References:

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Resources:

Table 2: Research on the Newborn Microbiome after IV Antibiotics for GBS.

First Author (Year)

Sample and Methods

Results

Notes

Jaureguy (2010)

Researchers collected stool samples from 50 newborns in France on day 3 after birth. Half of the infants were born to birthing people who had IV amoxicillin for GBS during labor, while the other half did not. Infants were matched for gestational age, vaginal or Cesarean birth, and breastfeeding or bottle feeding.

49 of the 50 infants tested positive for GBS bacteria by day 3 of life. The only infant who was not came from the antibiotics group. Bacterial presence was similar between groups, but there were fewer infants with C. difficile (a harmful bacteria) in the antibiotic group. They also found no difference in rates with antibiotic-resistant strains of bacteria.

This was the first study that compared bacterial colonization among infants who were exposed to in-labor IV antibiotics for GBS, versus those who were not exposed to IV antibiotics and the birthing people were not GBS carriers.

Fouhy (2012)

Researchers examined the gut microbiota of 9 newborns who were given IV ampicillin and gentamicin within 48 hours of birth. They took stool samples 4 and 8 weeks after the infants completed their antibiotics and compared the results to 9 untreated infants.

Infants who received antibiotics shortly after birth had much lower levels of beneficial bacteria, including Bifidobacterium and Lactobacillus. These good bacteria were replaced by members of the Proteobacteria family. Overall, the infants who received antibiotics shortly after birth had less diversity of their gut microbiome 4 and 8 weeks after antibiotic treatment, even though some beneficial bacteria had recovered.

The information from this study may or may not apply to birthing people who receive IV antibiotics during labor for GBS, because these infants received antibiotics after birth. The most common antibiotic given for GBS during labor is penicillin, with cefazolin, clindamycin, and vancomycin being given less frequently.

Keski-Nisula et al. 2013

Researchers collected vaginal swabs from 50 pregnant people approximately 21 days before birth. They also swabbed the baby's mouth immediately after birth. They only included parent-infant pairs in the final data analysis if the birthing person had Lactobacillus present in the vagina prenatally, and they excluded babies born by elective Cesarean when the membranes were intact. 17 people received antibiotics during labor-indications for the antibiotics included GBS, suspected chorioamnionitis, and Cesarean.

45 of the 50 participants tested positive for Lactobacilli in the last trimester, and 14 of their newborns had Lactobacilli dominant mixed flora after birth. The researchers found that longer duration of ruptured membranes and IV antibiotics during labor were independent predictors of a decreased transmission of Lactobacillus to the baby. Of babies born to the 45 participants who tested positive for Lactobacilli- only 1 baby exposed to antibiotics during labor carried Lactobacillus at birth, while half of the newborns (16 in total) who were not exposed to IV antibiotics during labor did not have any Lactobacillus present at birth.

Researchers are not sure why longer durations of ruptured membranes led to a decreased colonization with Lactobacillus. The researchers state that research is needed to determine if giving to probiotics to birthing people and newborns immediately after birth can help lessen the impact of IV antibiotics on the baby's microbiome.

Aloisio et al. (2014)

Collected stool samples from 52 newborns in an Italian NICU at 6 to 7 days after birth. Half of these newborns were born to participants who had IV antibiotics for GBS, and the other half were born to participants who were GBS negative and did not receive antibiotics during labor. All the babies were born vaginally at term and were exclusively breastfed/chestfed.

All types of bacteria that they tested for were present in both groups; however, the number (counts) of some types of bacteria differed between groups. In the group that was exposed to IV antibiotics during labor, there were lower counts of E. coli and Bifidobacterium, but there were no differences between groups in the average counts of Bacteroides fragilis group, lactobacilli, and C. difficile. In the newborns who were exposed to antibiotics during labor, there was less diversity of the Bifidobacterium that were present.

The authors stated that the most important difference was a significant reduction in bifidobacteria counts (one type of beneficial bacteria) at 1 week of life in infants whose birthing parents received IV antibiotics.

Aloisio (2016)

Collected stool samples at 7 days of age from 10 babies born to GBS-negative birthing people who did not receive antibiotics during labor and 10 babies born to GBS-positive birthing people who received antibiotics during labor. The 20 newborns in this study were in the NICU at the time their samples were collected and were all born vaginally at term and had been exclusively breastfed/chestfed. The authors used a special genetic (DNA) analysis to look at the genetic diversity of the bacteria, called "next generation sequencing."

The infants whose parents had not received antibiotics had a more "rich" and complex microbial profile, while the babies whose birthing parent had received in-labor antibiotics had very poor diversity of their microbiome, higher levels of gram-negative bacteria, and a decrease in beneficial bacteria such as Bifidobacterium, Bacteroidetes, and Actinobacteria. There were higher levels of gram-negative bacteria, Enterobacteriaceae, and Proteobacteria in the IV antibiotics group.

The authors stated that there were clear differences in the gut microbiome between the two groups at 1 week of age. They also state that the changes in the microbiome are consistent with what one would expect after administering an IV antibiotic like ampicillin that mainly acts against gram-positive bacteria, leading to an over-abundance of gram-negative bacteria.

Azad (2016)

Researchers enrolled 198 parent-infant pairs from a large Canadian cohort study. The infants included in this sub-study had stool samples collected at 3 and 12 months, and complete data about antibiotic exposure during labor and after birth. Infants were separated into 4 groups: no antibiotic exposure during labor with vaginal delivery (57%), antibiotic exposure with vaginal birth (21%), antibiotic exposure with elective Cesarean (9%), and antibiotic exposure with unplanned Cesarean (13%). Cefazolin was used during Cesareans, and penicillin was used during vaginal births. Researchers also measured the presence and duration of exclusive breastfeeding/chestfeeding. They used high through-put genetic sequencing to determine the infant gut microbiome.

Among vaginal births, GBS was the most common reason for antibiotic use during labor (76%), followed by prolonged rupture of membranes (24%). Half (52%) of the infants were exclusively breastfed/chestfed at 3 months, and half (49%) were still receiving human milk at one year.

The results showed that the infant microbiome was influenced by antibiotic exposure, route of delivery, and breastfeeding /chestfeeding. At 3 months, infants exposed to antibiotics during labor had a decreased level of Bacteroidetes, as well as a decrease in microbiome richness, regardless of breastfeeding status. The most severe deficiencies happened among infants born by Cesarean. Infants born by Cesarean also had higher levels of Clostridium, Enterococcus, and Streptococcus. At one year of age, most of the differences were gone, although some differences remained in infants who were not breastfed/chestfed for at least 3 months.

This was the most thorough study so far in terms of measuring antibiotic exposure during labor and during the first year of life, as well as breastfeeding. Breastfeeding/chestfeeding had the beneficial effect of helping the microbiome recover after antibiotic exposure-the benefits increased with exclusive feeding with human milk and with an increased duration. Although by one year of age the gut seemed to have recovered in all infants who were breastfed/chestfed for at least 3 months, the researchers were not able to rule out long-term health effects from the initial microbiome changes before that. It is not surprising that Bacteroidetes (a type of beneficial bacteria) were suppressed at 3 months following antibiotic exposure during labor, given that this type of bacteria is sensitive to penicillin and cefazolin.

Corvaglia (2016)

Researchers enrolled 84 healthy term infants whose birthing parents had all been screened for GBS. They excluded infants born by Cesarean, who received antibiotics after birth, those admitted to the NICU, or those whose birthing parents had antibiotics before labor. Stool samples were collected at 7 and 30 days of life, and infants were separated into two groups: those who were exposed to antibiotics during labor for GBS, or those who were born to a parent who was GBS-negative and did not receive antibiotics during labor. Researchers also collected info on breastfeeding/chestfeeding. None of the parents gave their infants probiotics after birth. They researchers counted the number of these beneficial bacteria: Bifidobacterium, Lactobacillus, and B. fragilis (includes Bacteroides).

The number of Bificobacterium was lower in the antibiotic group at 7 days of life, but there were no differences between groups at 30 days. There were no differences in Lactobacillus or B. fragilis group bacteria at either time point. There were higher counts of Bifidobacterium at 7 days among infants who did not receive antibiotics during labor and those who were exclusively breastfed/chestfed. By 30 days, there was no relationship between Bifidobacterium and feeding type or antibiotics.

The authors concluded that the counts of these bacteria were only temporarily lowered by antibiotic use during labor. However, this study is limited by its use of simple bacterial counts of only 3 bacterial groups, and no examination of microbiome richness, although they did use molecular techniques that improves the accuracy of bacterial counts.

Mazzola (2016)

Researchers enrolled 26 infants from the NICU in a hospital in Italy. Infants could be in the study if they were born vaginally at term, had a normal weight at birth (2.5 to 4 kg) and their mothers were screened for GBS at 35-37 weeks. Stool samples were collected at 7 days and 30 days of life. Infants were separated into 4 groups: breastfed/chestfed infants born to a GBS-negative parent who did not receive antibiotics during labor ("breast fed control"), breastfed/chestfed infants born to GBS positive birthing parent who received antibiotics during labor, mixed-fed infants born to GBS negative birthing people ("mixed fed control"), and mixed-fed infants born to GBS positive birthing people who received antibiotics during labor.

Among breastfed/chestfed infants, the researchers found a lower diversity of bacteria at 7 and 30 days in infants who received antibiotics during labor compared to the control group. The most prominent differences at day 7 were found with higher numbers of Enterobacteriacaea family ( Escherichia) and lower numbers of Bifidobacterium. By day 30, the bifidobacteria had recovered, but there were still higher levels of Enterobacteriaceae in the infants exposed to antibiotics during labor.

Mixed-fed infants exposed to antibiotics had higher numbers of Proteobacteria, Firmicutes, Streptococcus, and bacteria from the Enterobacteriaceae family when compared to mixed fed control infants at 7 days. The control groups who were mixed-fed had higher levels of Actinobacteria and Bacteroidetes, and Bifidobacterium at 7 days. By day 30, the two mixed-fed groups looked more similar in terms of their microbiome.

There was less diversity and richness in the microbiome of breastfed/chestfed infants exposed to antibiotics during labor, compared to mixed-fed infants exposed to antibiotics during labor.

These researchers are not sure why the breastfed/chestfed infants exposed to antibiotics during labor fared worse in terms of richness and diversity of their microbiome profile, compared to mixed-fed infants exposed to antibiotics. They propose that perhaps there are effects of the antibiotics on human milk when the birthing person is exposed to antibiotics during labor, but this needs further study. They also state that we need research on probiotic supplements to help newborns balance the microbiome after antibiotic exposure during labor.

Nogacka (2017)

Researchers collected samples from 40 infants in Spain at 2 days, 10 days, 1 month, and 3 months. All the 40 infants were born vaginally at term; 18 were exposed to IV penicillin during labor for GBS prevention, and 22 were not exposed. A total of 29/40 were breastfed/chestfed.

Levels of Proteobacteria decreased over time but were not statistically significant between groups. Infants exposed to penicillin during labor had higher levels of Firmicutes at 10 and 90 days. The non-exposed infants had higher levels of probiotics including Actinobacteria, Bacteroidetes, and others.

When they examined feeding patterns, they found that exclusively breastfed/chestfed infants who were not exposed to antibiotics had higher levels of Bacteroidetes at all time points and lower levels of Proteobacteria.

There was no statistical difference between groups in the presence of antibiotic resistant genes in the samples at 1 month.

This study provides additional evidence that breastfeeding/ chestfeeding can lessen the negative effects of antibiotics on the infant microbiome.

A larger sample size would be needed to accurately study the effects of antibiotics during labor on genes for antibiotic resistance (there was a trend but it did not reach statistical significance).

We would like to acknowledge Dr. Jessica Illuzzi, Associate Professor of Obstetrics, Gynecology, and Reproductive Sciences, and researcher who studies Group B Strep at Yale School of Medicine, for her expert review and assistance in writing the original article published in 2014. The 2022 revisions were reviewed by Ihotu Jennifer Ali, MPH and Shannon J. Voogt, MD.

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What is the evidence for antibiotics for group B strep during labor? Are there any alternatives? Can hibiclens, garlic, or probiotics treat GBS?

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Group B strep is a type of bacteria called streptococcal bacteria.

It's very common in both men and women and usually lives in the bottom (rectum) or vagina. It affects 2 to 4 women in 10.

Group B strep is normally harmless and most people will not realise they have it.

It's usually only a problem if it affects:

pregnant woman - it could spread to the baby

young babies - it can make them very ill

elderly people or those who are already very ill - it can cause repeated or serious infections

This page focuses on group B strep in pregnancy and babies.

Group B strep in pregnancy

Group B strep is common in pregnant women and rarely causes any problems.

It's not routinely tested for, but may be found during tests carried out for another reason, such as a urine test or vaginal swab.

Risks in pregnancy

If you have group B strep while you're pregnant:

your baby will usually be healthy

there's a small risk it could spread to your baby during labour and make them ill - this happens in about 1 in 1,750 pregnancies

there's an extremely small risk you could miscarry or lose your baby

What to do if you're worried

If you're worried about group B strep, speak to your midwife or GP for advice.

Talk to them about the risks to your baby and ask their advice about whether to get tested.

Routine testing is not currently recommended and tests are rarely done on the NHS, but you can pay for one privately.
Find out more about getting tested for group B strep on the Group B Strep Support website
What happens if you have group B strep

If tests find group B strep, or you've had a baby that's been affected by it before, you may need extra care and treatment.

You may be advised to:

speak to your midwife about your birth plan - they may recommend giving birth in hospital

contact your midwife as soon as you go into labour or your waters break

have antibiotics into a vein during labour - this can significantly reduce the risk of your baby getting ill

stay in hospital for at least 12 hours after giving birth so your baby can be monitored - this is not always necessary

Group B strep in babies

If you had group B strep during pregnancy, there's a small risk it could spread to your baby and make them very ill.

If this happens, it's usually soon after they're born. Your baby may be monitored in hospital for up to 12 hours to check for any problems.

They'll be given antibiotics into a vein if they develop symptoms.

What to look for after leaving hospital

Occasionally, symptoms of a group B strep infection can develop up to 3 months after birth.

Call 999 or go to A&E if your baby gets any of these symptoms:

being floppy or unresponsive

grunting when breathing, or working hard to breath when you look at their chest or stomach

very fast or slow breathing

a very fast or slow heart rate

an unusually high or low temperature

changes in their skin colour or blotchy skin

not feeding well or vomiting milk up

an unusually fast or slow heart rate

They may need treatment with antibiotics in hospital immediately.

Risks in babies

Most babies with a group B strep infection make a full recovery if treated.

Some babies may develop serious problems like sepsis or meningitis.

This can cause lasting problems like hearing loss or loss of vision. Sometimes it can be fatal.

More information

Page last reviewed: 12 March 2021
Next review due: 12 March 2024

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Group B strep is a type of bacteria called streptococcal bacteria. It's very common in both men and women and usually lives in the bottom (rectum) or vagina. It affects 2 to 4 women in 10. Group B strep is normally harmless and most people will not realise they have it.

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Five things parents should know if they decide to decline vitamin K for their baby - Dr Sara Wickham

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What information should we offer when parents decide to decline vitamin K? Sara Wickham offers an overview and an infographic.

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Good information about vitamin K is key for every parent.

In most countries, one of the first decisions that parents need to make for their baby is whether or not they want their baby to have vitamin K. If they do, it's usually given within the first hour of birth.

It's your decision whether or not your baby has vitamin K. It's also up to you to decide which kind of vitamin K (oral or injection) you want your baby to have. So you'll want to weigh up the pros and cons, as with every decision you'll make for your child.

I have been researching vitamin K for more than twenty years, and I have written several books and information leaflets on this subject. Here's the most recent.

I have written this summary of information about vitamin K that you might want to consider when making your decision. It's based on the information in my book, and you might also want to visit my vitamin K information hub, which offers a few more articles on vitamin K.

1. Vitamin K is offered in order to prevent a rare but serious blood clotting problem.

Vitamin K is needed in the human body for several key processes.

One of the most important is that it helps blood to clot.

This is why it is offered to newborn babies. Without it, a small number of babies will develop a rare but serious blood clotting problem.

We used to call this problem haemorrhagic disease of the newborn (HDN). It is now more commonly known as vitamin K deficiency bleeding (VKDB).

2. The likelihood of the problem is low, but it can be serious.

Exact figures vary, but the chance of a baby experiencing VKDB if they don't have vitamin K is about 1 in 11,000.

Most babies who have VKDB will recover, especially if they receive treatment quickly. This is why it is important to be vigilant if you decide to decline vitamin K.

A small number of the babies who experience VKDB will experience long-term damage and, sometimes, a baby will die. The actual chance of death from VKDB is very low, but if we give vitamin K to all babies, it's even less likely.

3. Vitamin K can be given by mouth or by injection.

Vitamin K can be given by injection, or your baby can have oral drops.

The drops may be given in several doses over the first few weeks of your baby's life.

Oral drops are not as effective as the injection, but some parents prefer to give vitamin K that way.

The timing and amount of vitamin K that is given orally can vary between areas of the world.

Vitamin K is also added to formula milk.

4. Vitamin K is very effective, especially when given by injection.

We do not have a randomised controlled trial into vitamin K.

However, other studies, audits and long experience suggest that vitamin K is very effective at preventing VKDB when given by injection.

Oral vitamin K is less effective than vitamin K given by injection. But oral vitamin K is more effective than no vitamin K. We don't have good data on exactly how effective oral vitamin K is.

5. Vitamin K is very safe, but there are a few downsides.

Compared to some drugs, vitamin K is considered very safe.

The injection of vitamin K will occasionally result in infection (at the injection site), bruising or bleeding (as with any injection). It can cause pain to the baby when it is being given.

There have been cases of the wrong drug being injected, but these are rare.

Some people are concerned about other possible downsides to vitamin K, because it hasn't been well researched.

We have given vitamin K to millions of babies for many years because we know that it prevents almost all cases of VKDB.

But we don't know why babies have a relatively low level of vitamin K (compared to adults). It may be that this is beneficial to them in some way.

No research has been done into this, and not enough research has been carried out into possible side effects.

The fact that so much is unknown makes the decision difficult for some parents.

6. There are alternatives; it's not always 'all or nothing'.

As with many birth and parenting decisions, it's not always an 'all or nothing' decision.

For instance:
You may decide to have oral vitamin K rather than the injection.
In this situation, be aware that Vitamin K is fat soluble. So in order to be properly absorbed by the baby's body, it should be given with or just after a feed. Also be aware that it tastes bitter. Many babies will try to spit it out again and you might want to have your finger ready to scoot it back in!
You may decide to wait and see and make a decision according to your situation.
There are a few key vitamin K information issues to consider. If your baby is breastfed and is slow to feed or has feeding problems, the chance of VKDB is higher and you may want to reconsider. If you or your baby have antibiotics, this can increase the chance of VKDB. Again, you may want to take that into account. Likewise if your baby has a procedure such as a tongue tie division or circumcision.

It is good to look into all aspects of this decision to make sure that you are fully informed.

7. It's up to you

As I said at the beginning of this blog post, this is your decision.

You have the right to have good information and make the decision that is right for you and your baby.

I hear from midwives and others in some areas of the world (notably the USA) that parents are sometimes told that it is illegal to decline vitamin K.

This may not be true, so please check what your rights are.

It is also the case that, unfortunately, some parents are put under pressure to accept vitamin K. In some situations, senior professionals are brought in to try to persuade parents to accept it.

If you are thinking of declining vitamin K, I really would recommend that you look further into this area. Here's a link to my book if you'd like to get more depth.

We have an entire information hub on this topic, with links to several more articles and blog posts.

And if you are thinking of declining vitamin K, please take a look at this information in particular.

Books to help you become informed and make the decisions that are right for you...

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Seven things every parent needs to know about vitamin K - Dr Sara Wickham

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Dr Sara Wickham, author of Vitamin K and the Newborn, shares information about vitamin K. Seven things every parent needs to know before making a decision.

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Show caption
Newborn ... 11.5% of mothers have a planned caesarean section in the UK. Photograph: Alamy

In Greece, mothers face hardship in pregnancy and trauma giving birth - in pictures
Women who give birth by caesarean typically stay in hospital a day longer and have an extended recovery period. There is also a higher risk of hysterectomy and cardiac arrest during the procedure - although this is still a tiny risk at 0.03% and 0.19% respectively.

Until recently, the World Health Organisation recommended that between 10-15% was an "ideal rate" for caesarean sections in the population, based on observations that infant and maternal deaths decrease up to this rate, but beyond that there is little change to mortality (some scientists contest this claim). The WHO now discourages the concept of "target rates", saying that the needs of a patient should be assessed on a case by case basis. This is partly due to a recognition that the risks associated with surgery have fallen substantially. Better anaesthetics have minimised the risk of deep vein thrombosis and less invasive surgical techniques make infection less likely.

That said, there is some evidence that a vaginal birth may have benefits for the baby. Doctors believe surges of hormones as labour begins may kickstart the baby's lungs, while being squeezed through the birth canal also helps expel amniotic fluid from the lungs, meaning that breathing problems are less common immediately after a vaginal birth.

In the long term, there is some evidence that children born by C-section are at greater risk of developing asthma and are more likely to be obese as adults.
Unanswered questions

This week an inquest found that Frances Cappuccini, a 30-year-old primary school teacher, died unnecessarily when a caesarean went wrong. What are the dangers - and the facts?

© 2022 Guardian News & Media Limited or its affiliated companies. All rights reserved.

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In Greece, mothers face hardship in pregnancy and trauma giving birth - in pictures Women who give birth by caesarean typically stay in hospital a day longer and have an extended recovery period. There is also a higher risk of hysterectomy and cardiac arrest during the procedure - although this is still a tiny risk at 0.03% and 0.19% respectively.

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MBRRACE-UK Saving Lives Improving Mothers' Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2019-21

MBRRACE-UK is pleased to announce the publication on the 12th October 2023 of the MBRRACE-UK Saving Lives, Improving Mothers' Care report for 2023. This year, as requested by NHS England, we have three shorter forms of the report containing limited surveillance and confidential enquiry results which are available below as the "State of the Nation" surveillance and themed reports. The full materials are available in the compiled report including the supplementary material.

Themed Surveillance Report

Themed Maternal Morbidity Report

Themed Maternal Mortality Report

MBRRACE-UK Perinatal Mortality Surveillance: Report for births in 2021

MBRRACE-UK is pleased to announce the publication of the MBRRACE-UK Perinatal Mortality Surveillance Report for Births in 2021. This is the ninth perinatal surveillance report and the first to be presented as a concise "State of the Nation" report. The report is accompanied by a set of reference tables, a data viewer with interactive mapping, and a technical manual. The report can be accessed on the TIMMS website

MBRRACE-UK Saving Lives Improving Mothers' Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20

MBRRACE-UK is pleased to announce the publication on the 10th November 2022 of the MBRRACE-UK Saving Lives, Improving Mothers' Care report for 2022. As requested by NHS England we also have a shorter form of the report this year containing only limited surveillance and confidential enquiry results which is available below as the 'Core Report'.

ERRATUM: Typographical error in Table 2.3 corrected in updated version

Slides from the meeting presenting the report can be downloaded from the Slide Presentations page.

We are pleased to be able to let you know that printed copies of the 'MBRRACE-UK: Saving Lives, Improving Mothers' Care 2022: Lessons to inform maternity care from the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2018-20' published on the 10th November 2022 are now available to purchase from our online store for a price of £10 per copy inc VAT and postage.
Buy my copy of the printed report now!
Back copies of the reports are also available to puchase. Further details are available here

MBRRACE-UK publishes three sets of reports:

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The National Perinatal Epidemiology Unit (NPEU) is a multidisciplinary research unit based at the University of Oxford. Our work involves running randomised controlled trials, national surveillance programmes and surveys, confidential enquiries, aetiological studies and a disease register. The results of our research sit at the nexus of public and population health sciences, clinical care and health policy development.

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Overview | Diabetes in pregnancy: management from preconception to the postnatal period | Guidance | NICE

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This guideline covers managing diabetes and its complications in women who are planning pregnancy or are already pregnant. It aims to improve the diagnosis of

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Evidence on: Induction for Gestational Diabetes - Evidence Based Birth®

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Some providers encourage people with gestational diabetes (GDM) to plan elective induction at early term since they are at increased risk of complications from high blood sugar. Is this an evidence-based recommendation? Find out in our new article all about induction for gestational diabetes!

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I created Gestational Diabetes UK in 2014 as a GD Mum, for other Mums. I'm dedicated to providing information, research and support on gestational diabetes, from diagnosis through to birth and beyond.

I do not show any ads on my website, or have any annoying pop-ups. There are no affiliate links and no financial gain for any products that are mentioned within the content. All links shown are purely for information purposes.

GD UK does not sell any physical products, instead, it is funded by an optional subscription to the website for additional GD UK recipes and 7-day meal plans.

By selling recipe subscriptions, it has meant that the Gestational Diabetes UK website can remain free for all to use.

If you would like to subscribe to the GD UK Recipe Subscription, please use the link below

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Gestational Diabetes UK * Gestational Diabetes UK

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Gestational Diabetes UK is dedicated to offering support and evidence based research to women diagnosed with gestational diabetes in the UK and Ireland

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𝗧𝗵𝗶𝘀 𝗶𝘀 𝘁𝗵𝗲 𝗼𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗮𝗻𝗱 𝗼𝗳𝗳𝗶𝗰𝗶𝗮𝗹 𝗚𝗲𝘀𝘁𝗮𝘁𝗶𝗼𝗻𝗮𝗹 𝗗𝗶𝗮𝗯𝗲𝘁𝗲𝘀 𝗨𝗞® 𝘀𝘂𝗽𝗽𝗼𝗿𝘁 𝗴𝗿𝗼𝘂𝗽 𝗯𝘆 𝘄𝘄𝘄.𝗴𝗲𝘀𝘁𝗮𝘁𝗶𝗼𝗻𝗮𝗹𝗱𝗶𝗮𝗯𝗲𝘁𝗲𝘀.𝗰𝗼.𝘂𝗸 👋 Welcome to Gestational Diabetes UK®, the official Gestational Diabetes UK Facebook Support...

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In this 2nd episode on gestational diabetes, we discuss the baby; what is hypoglycaemia, how does it affect babies, what are the signs, and how is it treated? We look at some of the evidence and latest guidelines for treatment of hypoglycaemia in the infant, as well as antenatal hand expression, what helps support a baby's glucose level after birth and the link between women with gestational diabetes and delayed onset of lactation (milk 'coming in' late) and its potential impact on future breastfeeding. And of course, how to get breastfeeding off to a good start. A jam-packed episode to complete our whirlwind tour of GD.

LINKS:
Our Patreon account https://www.patreon.com/themidwivescauldron

Dr Rachel Reed - Gestational Diabetes blog https://midwifethinking.com/2018/03/20/gestational-diabetes-beyond-the-label/

Hypo EXIT - Lower versus Traditional Treatment Threshold for Neonatal Hypoglycemia. https://www.nejm.org/doi/full/10.1056/NEJMoa1905593

ABM #1 Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021 https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/Protocol%20%231.pdf

Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebo-controlled trial https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61645-1/fulltext
Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31373-9/fulltext

Lily Nichols- Real food for pregnancy https://lilynicholsrdn.com/books/

Support the show Please support the show via Patreon or BuyMeACoffee MERCH here! Music Joseph McDade Like this podcast? Leave us a review here
Want more from Katie and Rachel?
Katie's website
Rachel's website

Disclaimer
The information provided on this podcast does not, and is not intended to, constitute medical or legal advice; instead, all information available on this site are for general informational purposes only. The Midwives' Cauldron podcast reserves the right to supplement, change or delete any information at any time.

The information and materials on the podcast is provided "as is"; no representations are made that the content is error-free. Whilst we have tried to ensure the accuracy and completeness of the information we do not warrant or guarantee the accurateness.

The podcast accepts no liability for any loss or damage howsoever arising out of the use or reliance on the content.

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gestational diabetes: the baby's perspective

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‎The Midwives' Cauldron: Gestational Diabetes: the baby's perspective on Apple Podcasts

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In this 2nd episode on gestational diabetes, we discuss the baby; what is hypoglycaemia, how does it affect babies, what are the signs, and how is it treated? We look at some of the evidence and latest guidelines for treatment of hypoglycaemia in the infant, as well as antenatal hand expression, wha...

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‎The Midwives’ Cauldron: Gestational diabetes: the pregnancy perspective on Apple Podcasts

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‎Show The Midwives’ Cauldron, Ep Gestational diabetes: the pregnancy perspective - 26 Jun 2021

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What are the best questions to ask if you're offered induction of labour?

This is something I get asked a lot. So I have put together this guide to the five best questions that you can ask in order to get more information and make the decisions that are right for you.

I'm also going to tell you what you can learn from the answers you are given.

In case we've not met before, my name is Sara. I'm a midwife, speaker, researcher and the author of two books about induction of labour. They are In Your Own Time and Inducing Labour: making informed decisions. I've also written a book to help women and families make birth decisions. That's called What's Right For Me?

Here's the important thing. I'm not here to tell you whether to have your labour induced or not. That's not up to me. (Or your midwife, obstetrician, childbirth educator, doula or hypnobirthing teacher, but we'll come back to that.) Your decision won't affect me or any of those people. And, as I am very fond of saying, one size doesn't fit all. My work is about trying to help you to understand and navigate the evidence so you can make the decisions that are right for you.

Let's start with what I think is the first question anyone should ask if induction is mentioned.

Question 1: Why are you suggesting this? / What's the indication?

The first thing you need is a clear and specific explanation of why you're being offered induction of labour. So "why" is the first question to ask.

Midwifery and medical professionals call this "the indication." Asking "what's the indication?" will help you find out whether or not there is a clear, single indication. But you don't have to use the jargon. You could also ask, "Why are you suggesting this?" Or, "Can you tell me exactly why you're offering me induction?"

You might have to ask this - and the other questions - more than once. Don't be afraid to do that. It's your body and your baby, and the decisions you make can affect you and your baby's health and you family for a long time. So unless you're in one of those rare situations where it's really an emergency, it's really okay to take time to think about them.

And one tip is that, if it's truly an emergency, you're not likely to be offered an induction. Induced labour often takes three days to get going. If there's a genuine emergency, you'll be offered a caesarean, which is much faster. So if someone offers you an induction and says it's an emergency, you might want to ask some questions about that.

What can you learn from the answer?

There are three common answers to questions about why induction is being offered.

"You or your baby have a medical problem."

The answer you get may be very clear and specific and mention an actual medical problem.

For instance, you might be told, "because you have pre-eclampsia." Or, "because your baby has a heart condition and we need him to be born so we can do surgery."

In these situations, it's still your decision, of course. And yes, there's a difference between having symptoms of pre-eclampsia and being close to developing eclampsia. So you might want to explore what you're being told in a bit more depth. You'll still want to ask the remainder of the questions below, and you can then decide whether or not the benefits of induction outweigh the downsides for you and your family. But where there's a clear and specific reason that involves an actual medical condition, it's more likely that induction is genuinely warranted.

This is a useful thing to know. Because there's an important difference between being offered induction because you or your baby actually HAS a specific named medical condition, and being offered induction because you or your baby is thought to be "at risk" of something. It's important to determine which is the case for you.

You might be told that you're being offered induction because you or your baby are "at higher risk." When you ask what that means, you discover that it's because you are for example over a certain age, larger than average, or you conceived by IVF.

None of those things are an actual medical condition. So let's look next at what you might want to consider if you're told you're being offered induction because you have one or more risk factors.

"You have a risk factor."

The second possible answer is that you are told something like this:

"We offer induction to everyone who is 41 weeks pregnant."

"Your BMI is over 35."

"We offer induction to everyone who has a suspected big baby."

"Induction is best for women who conceived by IVF or ARTs."

That list isn't exhaustive; they are just a few examples.

What this kind of answer tells you is that the offer isn't tailored to your specific, individual situation. You're being offered induction because you fall into one or more categories. In many countries, induction is routinely offered on a population basis to anyone who ticks a box or has a 'risk factor.'

You might still want induction in these circumstances, but it's important to know that having a risk factor is different to having an actual medical condition. Having an actual, diagnosed medical condition right now is different from being in a group that might be at greater risk of developing a problem. Most of the time, only a small number of those in the group will develop a problem, whereas someone with a medical condition definitely has that condition.

Often, the actual chance of women who are told they are "at risk" having a poor outcome is very low. More on what to ask about the numbers below. In many cases, there's still a very high chance of everything being just fine. And remember that induction has downsides too and life doesn't come with a "no risk" option.

This is where you really need to look at the evidence and weigh things up. Sometimes, induction is offered to women with risk factors in the hope of saving a very small number of babies. But there's not always clear evidence that it does save babies. And hundreds or thousands of women and babies need to have induction in the hope of saving one. Some of them will end up with other problems as a result of the induction and associated interventions, and so it's a question of weighing up the pros and cons. Often, there isn't good evidence to support induction for risk factors alone. There are some articles on this on our induction information hub and loads more on the evidence in In Your Own Time. And there's more on how to ask about the actual numbers below.

"Mumble, waffle, jargon, jargon."

The third common answer to this question is a reply that is unclear, provides little information or is full of jargon. Someone may list several potential problems or risk factors in an unspecific way that leaves you wondering what they just said. Don't let that put you off asking more questions. A garbled, unclear, or 'stun you with science' response may mean that the person you're speaking with is not really keen on you making your own decision. It might mean that there isn't a clear indication. If someone has to add three risk factors together to justify their offer but can't provide you with robust evidence for any of them, be wary.

It might be that the person offering induction may be afraid of physiological labour, or of waiting for women to birth in their own time. (It's more common than you might think.) They may genuinely think this is 'for the best', or just prefer to control when labour happens.

If you are given a list of complications or risk factors, ask lots of questions about what these complications are. Ask the questions below as well. There's more about this in my blog post on induction for gestational diabetes. Look at the section in that blog post called "Risks and recommendations." Even if you've not been told you have gestational diabetes, the principles are the same.

Don't be impressed by jargon. If an intelligent person has a justifiable suggestion, they should be able to explain and discuss it with you in a reasonable manner. If that's not happening, be alert.

This brings me to my next tip.

Question 2: What's the evidence?

Once you've discovered exactly why induction is being recommended in your situation, ask what the evidence says. This is another of the key questions to ask if you're offered induction. Ask if there is evidence of benefit of induction. Often there is not. And, if someone tells you that there is evidence of benefit, ask them to provide you with the evidence or a reference, so that you can look at it for yourself.

One thing that's important to know is that not all induction studies are good studies. Some were poorly conducted and/or were biased in their approach. This is especially true of some of those which claim to show that induction reduces the chance of caesarean section. Some studies are now quite old. It's possible the participants weren't similar to you. For instance they might not have given birth in the setting/country that you're in. This kind of evidence may not necessarily apply to you.

This is a complex area and I can't give all the detail here (which is one reason I write books for those who want more in depth information). But some of the more controversial studies to listen out for include The Canadian Post-Term Trial, the ARRIVE Trial, and the SWEPIS study. The last one is sometimes described as a Swedish study which was stopped because some babies died. Yes, they did, which is very sad. But that doesn't mean they would have been saved by induction, or that a lack of induction was the problem. The media headlines and those who quote this study have been criticised by other researchers. That's because there were some issues with the trial. Data from a half-finished study isn't robust enough to let us draw conclusions and make recommendations. Again, if you'd like more detail, have a look at my other induction blog posts or grab one of my books.

What can you tell from someone's reply to this question?

Well, you're looking for a reply that is clear, honest and that acknowledges that no research study is perfect. If you feel that the person is trying to convince you that they are absolutely right and there's no room for debate, be alert. If they try to stun you with science and numbers, they may not really be wanting you to make your own decisions. Good practitioners will be happy to share the evidence with you and discuss the pros and cons in an open way that focuses on what's right for you.

Question 3: What's the absolute risk?

If you are told that there is a specific reason for induction, especially if that is a risk factor, ask for some numbers.

Some professionals will tell you the relative risk of something happening but not the absolute risk. So they might say, "your baby is twice as likely to die if you do X rather than Y." But what they don't tell you is that the risk of Y is one in 4000 and the risk of X is one in 2000. In other words, the unwanted outcome is very, very unlikely no matter what you do.

And, as we'll get to in the next tip, intervention carries downsides as well as advantages.

It's always a good idea to ask for the absolute risk of a problem occurring, no matter what health decision you're making. As with the last tip, you may also want to ask for the evidence or a reference so you can look at it yourself.

Also as with the last tip, you should be able to tell a lot from their response. All of the things I've mentioned about this above apply here as well. How open and honest are they in their response? Is there acknowledgement that there's not always one clear 'correct' way that's right for everyone?

Question 4: What are the downsides?

You should also ask about the downsides of induction.

I recommend asking this question even if you feel you already have this information. If you've been to my website before, you may already know that induction has downsides. ( If not, there's lots more info on that here. I recommend that families ask this question even if they already know what the downsides are.

That's because asking this question is an excellent way of finding out if the person you are speaking to is being open and transparent about the pros and cons of the different options. Anyone who is being respectful should honestly and openly tell you the things in this article. They should also mention the negative consequences of induction for you and your baby.

If they don't tell you these things, or they gloss over them, treat it as a red flag. You need the full picture. And you deserve caregivers who will give you that.

Question 5: How, when, where, what and who?

Find out about the process of induction, the pros and cons, the evidence for the most common reasons and the information you need to decide if it's right for you.

Don't be afraid to keep asking until you have enough information. If you want to be prepared before you have this conversation, there is also lots of info on the practical reality of induction in Inducing Labour: making informed decisions.

Many women are dissatisfied with their experience of induction. This is one of the key issues that comes up in the studies that ask women about their experience. One of the main reasons for this is that they had not been given adequate information about what would happen. They were not told, for instance, that induction can sometimes take three or four days to get going. They were not told that the early contractions can be quite painful, even though they may not be doing much. Women aren't always told that their partner, family, friends or doula can't be with them except during visiting times. These hours are quite restricted in some places. In others, they aren't. The induction experience varies a lot; it's a postcode lottery.

So ask as many questions as you need to in order to get a sense of what it would be like in your area. Then, you will be much better placed to weigh this up with all the other information you've gathered and decide whether induction is right for you and your baby.

So those are my five best questions to ask if you're offered induction. I hope that these questions will help you consider and explore your options. There's lots more induction information on this website. Make a cup of tea and have a look around!

If you'd like more in-depth information or to learn more about the evidence, you might enjoy In Your Own Time and/or Inducing Labour: making informed decisions. My book What's Right For Me? also contains lots of information about birth-related decision making.

Books to help you become informed and make the decisions that are right for you...

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Five questions to ask if you're offered induction of labour - Dr Sara Wickham

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What are the best questions to ask if you're offered induction of labour? Here are 5 great questions and what you'll learn from the answers.

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"The obstacles of new parenthood can feel impossible to navigate. As a new mother, I was exhausted; nobody told me that I would have to carry my baby everywhere. I was emotionally drained, while being bombarded with conflicting advice from just about everyone I knew. Then I hired a Baby Walk Consultant. Apparently, babies can walk from as early as eight weeks, making life so much easier for parents. Yes, you can train your baby to walk - the key is consistency. As soon as your baby shows signs of being able to stretch her legs, she is ready to walk. It won't take long - three days seems to be the magic number. Your baby may cry (sometimes for hours) but that is totally normal and all part of the process. The key is to be consistent. Resist the urge and do NOT respond to your baby's cries. Just stand your baby on her legs, shut the door and leave her for twelve hours. In the beginning, this may be heart-breaking as your baby will 'protest' and may even vomit; rest assured this is completely normal. Remember that your baby is trying to manipulate you. After all, they prefer to be carried, but babies can and should walk from eight weeks of age. The key to independent walking is that they need to teach themselves - it's called 'self-walking'. If you fail to be consistent your baby might not walk until she is 18 months old! Imagine how exhausted you will feel after carrying your baby around for all that time! You might feel that eight weeks is too early for babies to learn to walk, but that is simply not true. "Certified and Qualified" Baby Walk Consultants guarantee that babies can walk from as little as eight weeks. Because, as we all know - a baby that walks at eight weeks and does not rely on their parents to be carried everywhere is a GOOD BABY."
A mother recently sent this tongue-in-cheek passage to me, asking if I would post it anonymously. Why anonymously?

Because the notion that babies can and should sleep through the night independently has become so normalized in western culture, that those who dare to question its validity are stereotyped as soft, inept and unwilling to do what needs to be done.

There is no denying that night time parenting pushes us to our limits. Modern society has fragmented the community that was designed to share the load and act as a safety net when new parents need it most. Most families require both parents to earn an income and in many western countries, especially the US, maternity leave is abysmally inadequate.

But, that doesn't condone systematically dismissing normal infant behavior and labelling it as a "problem" that needs to be "fixed". As this mother suggests, it is as ridiculous and futile as expecting newborns to learn to walk; as dangerous as misdiagnosing health as disease. If we are to truly solve the issues surrounding parental exhaustion, we need to accurately identify the problem before we can have any hope of solving it, no matter how unconventional the solution may seem.

If we condemn infants for completely normal behavior we disconnect ourselves not only from our babies but from our instincts.

Mothers begin believing that 'experts' know what her baby needs more than she does; she begins reading the clock rather than her baby's cues and her confidence in her maternal abilities wanes. Because, as inconvenient as it may be, it is NORMAL for babies to wake every few hours, nurse and fall asleep at the breast for six, twelve, twenty-four months or longer.

Motherhood is inescapably exhausting but western habits and cultural ideals surrounding infant sleep are making it infinitely more difficult than it needs to be.

Desperate parents are understandably tempted by tough tactics but it doesn't need to be this way.

Countercultural mothers who lie in the dark, night after night, nourishing, comforting and connecting with their babies deserve to be supported, not chastised. Yet, our misguided society tells us that if we hold our babies, we're preventing independence. That if we soothe their souls, we're spoiling them. That if we nurse them to sleep, we're creating 'bad' sleep associations.

Thankfully, as natural parents, we know better than that. Our tender experiences of sharing sleep with our babies trumps the most elaborate and ingrained of mainstream scare tactics. Our maternal instincts override artificially created cultural ideals. And we simply don't buy the misinformation sleep trainers are selling.

So, we ignore convention and nurse our babies to sleep anyway.

We welcome our children into our beds, sometimes for years longer than we ever imagined. We rock and sing and cuddle our children to sleep in the wee small hours of the morning. We push ourselves to find gratitude in the difficult moments of parenthood, for there is untold beauty and opportunity for personal growth in this unifying and necessary human struggle. We share our hopes, dreams and fears in Facebook groups, seeking refuge in the compassion of online friends who offer us the sense of belonging we crave, but can't find in our day to day lives.

And sometimes we turn to sarcasm and humor to shed light on the commonly accepted views that babies are capable of more than they truly are. Sometimes a change in perspective is all we need to question an accepted practice. So, I thank my sister in the night, who I hope I will meet one day, for her words that inspired reflection and for challenging us to view our babies needs through a different lens.

"Make your choices based on LOVE not FEAR." Elisabeth Kubler-Ross

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Parents Need More Rest, But Sleep Training Isn't the Answer - Raised Good

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"The obstacles of new parenthood can feel impossible to navigate. As a new mother, I was exhausted; nobody told me that I would have to carry my baby everywhere. I was emotionally drained, while being bombarded with conflicting advice from just about everyone I knew. Then I hired a Baby Walk Consultant.

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I cannot tell you how many times I hear the words "s/he slept so well between 10 and 16 weeks, we were getting five, six, even seven hour stretches in the crib/bassinet/basket and s/he would settle back to sleep easily and quickly after a feed. Things started to go wrong at around four months, I don't what we did wrong, s/he was such as good sleeper, but since then it's all been downhill. I just don't understand".

We ('we' meaning society) seem to think that baby sleep is linear. By that I mean we seem to think that it gets better as babies grow older. Or at least we believe it is static, ie. it won't get worse again. The thing is, it's not linear (certainly not in an upwards trajectory) and it's not static. It goes up and down (mostly down in the first year). This is entirely normal and very, very common (that doesn't mean there is anything wrong if your baby's sleep got better and better, you're just in the lucky minority!).

This chart is far more representative of what happens sleep wise in the first 18 months. Yes it is depressing, but it's realistic and once you know that something is totally normal, not your fault and most importantly *not permanent* it is so much easier to relax a little.

As it happens, 3 months is the peak of sleep in the first year, that means it's as good as it gets. There is a very, very high likelihood that your baby will sleep the best they are going to sleep until their first birthday (and later) around the age of about 3 months. It's really not uncommon for 3 months to be happy to be put down, to only wake once or twice in the night and to go to sleep easily after a quick feed/cuddle.

Then 4 and 5mths happen, they're not fun months. You get lulled into a false sense of security at 3mths, then suddenly your baby is waking every hour, won't be put down and is awake for an hour or more refusing to go back to sleep. This is normal development, it is temporary and you didn't do anything wrong! You also don't need to do anything to change it, keep doing what you're doing. Don't be scared of bad habits and especially don't consider sleep training. It's temporary!

You often get a blissful little blip of better sleep around 5-6mths, then just when you think "finally, it's getting a bit better", bam, thinks get worse again, usually not as bad as they were at 4mths, but still far worse than you'd hope.

7-8/9mths are often months that promise hope, with any luck you'll be back somewhere to where you were around 3mths (but probably not as good), but then - oh my goodness - 8-10mths hits. This is the worst sleep gets in the whole of the first year. At this age 84% of babies are waking (and feeding) regularly at night. Who would have thought that your baby would sleep significantly worse at 10mths than they did at 3?!!

Thankfully from around 11mths things start to improve again, fairly steadily for the next 6mths or so (although not the golden heyday of 3mths!). You can still expect nightwaking and night feeds at this age though.

I didn't draw the rest of the chart, as it's a bit depressing, but when can you expect 'good' sleep fairly reliably? somewhere between 2-3yrs of age (there is a common dip at about 2.5yrs however). That's a *lot* later than most people think and certainly a lot later than most professionals advise, but it's the reality, it's just such a shame that we've lost touch with reality when it comes to infant sleep! The secret to all of this is you - what you can do to stay calm, rested and able to cope with this normal sleep pattern. Having realistic expectations is a huge start.
The NEWLY UPDATED Gentle Sleep Book - out now! If you would like to understand and learn how to improve your baby, toddler, or pre-schooler's sleep WITHOUT cry-based conventional sleep training, this is the book for you! p.s: Come and chat with me on Facebook, Twitter and Instagram Or watch my videos on YouTube You can also sign up for my free parenting newsletter HERE.

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We ('we' meaning society) seem to think that baby sleep is linear. By that I mean we seem to think that it gets better as babies grow older. Or at least we believe it is static, ie. it won't get worse again. The thing is, it's not linear (certainly not in an upwards trajectory) and...

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Great pregnancy fitness you tube channel. 

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Great pregnancy fitness you tube channel. 

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"prenatal yoga" "pregnancy exercises" "diastasis recti" "weight loss" "weight loss after baby" "how to lose weight after pregnancy" "what to eat for weight l...

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Pregnancy and postpartum fitness and yoga, birth education, core healing after pregnancy, healthy weight loss without dieting in a sustainable way. We've also added fun kids workouts! Prenatal Topics: 1. Prenatal yoga and fitness classes 2. Tips and tricks for an easier and faster labor 3.

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Planned caesarean section at North Bristol NHS Trust

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Baby Check App

Baby Check features 19 simple checks that parents can do if their baby is showing signs of illness. Each check tests for a different symptom and when completed, a score is calculated that tells parents or carers how ill their baby is. The app then lets parents know whether their baby needs to see a doctor or health professional.

Download for FREE from Google Play or the App Store.

Buy posters, business cards and other materials to help promote Baby Check to your clients and patients

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The Baby Check App helps parents decide if their baby needs to see a doctor or health professional

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C-sections - everything you need to know

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A caesarean section (c-section) may be planned or unplanned. Find out why you may need a c-section and what to do if you would like to have one.

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What is the issue?
Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently?
Why is this important?
Monitoring babies' heartbeats is used to check wellbeing during labour. Listening and recording the baby's heartbeat aims to identify babies who are becoming short of oxygen and may benefit from an early delivery by caesarean section or instrumental vaginal birth.

A baby's heartbeat can be monitored intermittently using a special trumpet-shaped device, or hand-held Doppler device. The heartbeat can also be checked continuously using a CTG machine. Continuous CTG produces a paper recording of the baby's heart rate and the mother's labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.
What evidence did we find?
We searched for evidence on 30 November 2016, but found no new studies for this update. We included 12 trials that compared continuous CTG monitoring with intermittent listening, and one trial compared continuous CTG with intermittent CTG. Together, the trials involved over 37,000 women. No trial compared continuous CTG with no monitoring. Most studies were undertaken before 1994, and apart from two, were not high quality. The review was dominated by one large, well-conducted trial from 1985 which involved almost 13,000 women who received one-to-one care throughout labour. The mothers' membranes were ruptured artificially as early as possible and about a quarter received oxytocin to stimulate contractions.

Overall, there was no difference in numbers of babies who died during or shortly after labour (about one in 300) (low quality evidence). Fits in babies were rare (about one in 500 births) (moderate quality evidence), but occurred less often when continuous CTG was used to monitor the baby's heart rate. There was no difference in the rate of cerebral palsy (low quality evidence); however, other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with significantly more deliveries by caesarean section (low quality evidence) and instrumental vaginal births (low quality evidence). Although both procedures carry risks for mothers, these were not assessed in the included studies.

There was no difference in numbers of cord blood acidosis (very low quality evidence), or women using any drugs for pain relief (low quality evidence) between groups.

Compared with intermittent CTG, continuous CTG made no difference to how many women had caesarean sections or instrumental births. There was less cord blood acidosis in women who had intermittent CTG but this result could have been due to chance.
What does this mean?
Most studies were undertaken many years ago and showed benefits and problems with both methods of monitoring the baby's wellbeing in labour. Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women's coping strategies. Women and their doctors need to discuss the woman's individual needs and wishes about monitoring the baby's wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

If you found this evidence helpful, please consider donating to Cochrane. We are a charity that produces accessible evidence to help people make health and care decisions.

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.

The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).

Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Read the full abstract...

Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

Data collection and analysis:

Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

We included 13 trials involving over 37,000 women. No new studies were included in this update.

One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.

Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).

Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).

Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.

Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

# data[].attributes.attachment_link.title
Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

# data[].attributes.attachment_link.description
What is the issue? Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently? Why is this important? Monitoring babies' heartbeats is used to check wellbeing during labour.

# data[].attributes.attachment_link.readable_text
What is the issue?
Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently?
Why is this important?
Monitoring babies' heartbeats is used to check wellbeing during labour. Listening and recording the baby's heartbeat aims to identify babies who are becoming short of oxygen and may benefit from an early delivery by caesarean section or instrumental vaginal birth.

A baby's heartbeat can be monitored intermittently using a special trumpet-shaped device, or hand-held Doppler device. The heartbeat can also be checked continuously using a CTG machine. Continuous CTG produces a paper recording of the baby's heart rate and the mother's labour contractions. Although continuous CTG provides a written record, mothers cannot move freely during labour, change positions easily, or use a birthing pool to help with comfort and control during labour. It also means that some resources tend to be focused on the need to constantly interpret the CTG and not on the needs of a woman in labour.
What evidence did we find?
We searched for evidence on 30 November 2016, but found no new studies for this update. We included 12 trials that compared continuous CTG monitoring with intermittent listening, and one trial compared continuous CTG with intermittent CTG. Together, the trials involved over 37,000 women. No trial compared continuous CTG with no monitoring. Most studies were undertaken before 1994, and apart from two, were not high quality. The review was dominated by one large, well-conducted trial from 1985 which involved almost 13,000 women who received one-to-one care throughout labour. The mothers' membranes were ruptured artificially as early as possible and about a quarter received oxytocin to stimulate contractions.

Overall, there was no difference in numbers of babies who died during or shortly after labour (about one in 300) (low quality evidence). Fits in babies were rare (about one in 500 births) (moderate quality evidence), but occurred less often when continuous CTG was used to monitor the baby's heart rate. There was no difference in the rate of cerebral palsy (low quality evidence); however, other possible long-term effects have not been fully assessed and need further study. Continuous monitoring was associated with significantly more deliveries by caesarean section (low quality evidence) and instrumental vaginal births (low quality evidence). Although both procedures carry risks for mothers, these were not assessed in the included studies.

There was no difference in numbers of cord blood acidosis (very low quality evidence), or women using any drugs for pain relief (low quality evidence) between groups.

Compared with intermittent CTG, continuous CTG made no difference to how many women had caesarean sections or instrumental births. There was less cord blood acidosis in women who had intermittent CTG but this result could have been due to chance.
What does this mean?
Most studies were undertaken many years ago and showed benefits and problems with both methods of monitoring the baby's wellbeing in labour. Continuous CTG was associated with fewer fits for babies although there was no difference in cerebral palsy; both were rare events. However, continuous CTG was also associated with increased numbers of caesarean sections and instrumental births, both of which carry risks for mothers. Continuous CTG also makes moving and changing positions difficult in labour and women are unable to use a birthing pool. This can impact on women's coping strategies. Women and their doctors need to discuss the woman's individual needs and wishes about monitoring the baby's wellbeing in labour.

Future research should focus on events that happen in pregnancy and labour that could be the cause of long term problems for the baby.

If you found this evidence helpful, please consider donating to Cochrane. We are a charity that produces accessible evidence to help people make health and care decisions.

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.

The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).

Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Read the full abstract...

Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

Data collection and analysis:

Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

We included 13 trials involving over 37,000 women. No new studies were included in this update.

One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.

Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).

Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).

Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.

Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

# data[].attributes.attachment_link.title
Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

# data[].attributes.attachment_link.description
What is the issue? Is continuous cardiotocography (CTG) to electronically monitor babies' heartbeats and wellbeing during labour better at identifying problems than listening intermittently? Why is this important? Monitoring babies' heartbeats is used to check wellbeing during labour.

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TED-Ed: The surprising effects of pregnancy

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Muscles and joints shift and jostle. The heart's pounding rhythm speeds up. Blood roars through arteries and veins. Over the course of a pregnancy, every organ in the body changes. Initiated by a range of hormones, these changes begin as soon as a pregnancy begins.

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Woman Explains Contractions With A Balloon

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45 Comments Sunday, 3 February 2019

Understanding Your Nappies
Using real nappies is not hard, just different from using disposables. You need to bear in mind that a "cloth nappy" will usually comprise of a number of parts; the nappy itself provides the absorbency, whilst the outer wrap (cover) provides the waterproof layer. On some nappies, these may be a single combined "all in one", like a disposable is.

On top of the nappy, you would normally use a washable or disposable liner. The liner acts as a barrier to catch any poo, which can then be flushed down the toilet. At night, you may need to add extra absorbency in the form of a booster pad, so that the nappy will last 12-14 hours without a change. This is just a pad of cotton or bamboo effectively an extension of the nappy.

How to Care for your Nappies

It's very simple! When you take the nappy off your child, flush any poo down the toilet and put the nappy and any washable liner in a nappy bucket. You do not need to change the wrap with every nappy, only if it gets soiled, or at the end of the day (or night). If any poo has missed the liner and the nappy itself has got soiled, you will find it best to rinse it through before it goes into the nappy bucket, to stop any stains from setting.

Before your nappies go into your storage bucket/bag make sure all hook and loop fastenings are done up so that they cannot catch on stray loops, otherwise your nappies will all end up in a big ball. Some fastenings come with laundry tabs and can be folded back on themselves. Otherwise you can simply do the nappy or wrap up on the widest setting and turn it inside out. This also protects the loop (soft) velcro, as well as stopping the hook velcro from doing any damage.

Drypailing v Soaking Storage
Traditionally nappies would be soaked in a bucket before washing but we DO NOT recommend this now. Just place your nappies in a dry bucket (dry pailing) until you're ready to wash them and then your washing machine will do all the hard work. It is much easier to load the nappies into the washing machine from a dry bucket and you can also keep your nappy wraps in the bucket along with the nappies. There will be no significant smell from the nappy bucket when the lid is lifted. Do not leave your soiled nappies in the nappy bucket longer than 2 days before washing as extended time left soiled will eventually damage nappy fabrics. The longer nappies are left between washing the longer nappies are exposed to ammonia.

If you decide to go against our advice and soak your nappies you should only use plain water. Soaking does effectively pre-clean the nappies a bit, which helps keep stains from setting. However, the downside is that the nappy bucket will smell when you take the lid off, you also have to dispose of the dirty water and soaking can damage modern fabrics and fastenings. It is also important to remember never to soak your wraps as this will cause them to lose their waterproofing. Use of soaking agents including vinegar, bicarbonate of Soda, Napisan, bleach or harsh stain removers should never be used as they can corrode the nappy fabric and cover binding and effectively destroy your nappies. Please note that if any of these products are used on the nappies or accessories it will invalidate your manufacturers product guarantee. Bamboo is an especially delicate fabric and is particularly susceptible to harsh chemicals.

Do not use laundry detergent products containing sodium percarbonate, hydrogen peroxide (oxygen bleach) or optical brighteners these ingredients are often listed. When combined with uric acid and ammonia a reaction occurs causing natural fibres to dissolve. These ingredients are also harsh on nappy covers and cover binding. We sell the Care of Motherease Nappies and Wraps
The binding on the Motherease products are the reason they are so fabulously waterproof so it's important to treat the binding with respect and make sure it can't get caught on velcro in the wash. When washing your Motherease wraps always protect from any velcro items. Place them in a mesh washing bag separate from anything that could catch on the binding like Velcro to keep them in excellent and reliable condition. Motherease approved Country Breeze and Laundry Magic stain remover on our site

Step1. Loading the Machine - Washing Load Size
Modern washing machines comes in all different size drums now so there is no hard and fast rule I can tell you as to how many you should/could get in a machine. You can also get more newborn sized nappies in a washing machine drum than you can big toddler nappies. As a guide you should be aiming to have your washing machine NO MORE than 3/4 full when dry. If you put too many into your drum and jam it full, your nappies won't have enough water to fully wash them and there won't room for them to move around and agitate - nappies need a lot of jiggling to get washed. If you put too few in then this can unbalance your machine so they don't spin properly but can also lead to excessive detergent bubble formation. If you don't have enough nappies to make up a wash add in mucky bibs, muslins or anything that would benefit from a deep long wash (husband's football kit was known to go in occassionally!)

Step 2. Rinse Cycle
When the time comes to do a wash, put the nappies in the machine and do a cold rinse cycle without any detergent, a rinse cycle is better than a prewash as modern machines are so water efficient they often reuse water from a prewash cycle whereas rinse cycle water is always fully drained away. Cloth nappies will be heavily soiled so we don't want any of the water used from the first rinse reused in the main wash. The rinse cycle removes any remaining solids and flushes away urine.

Step3. Main Wash Cycle
Next simply run your longest 60 or 40 degree wash depending on your nappy brands temperature recommendation, this is normally a cotton wash and never an ECO cycle. Use an extra water function if your machine offers this. Use an approved detergent for your nappy brand and dose (see below for dosage). This is USUALLY a non bio powder washing detergent however you must check your nappy brands specific detergent/ingredients guidelines (see below). Recommended Spin speed 1000rpm

The Nappy Lady believes for hygiene reasons you SHOULD wash at 60 degrees in any of the following circumstances however be aware of any warranty temperature limits:

If your baby is under about 3 months old (whilst they have no real resistance of their own)

If using Eco Balls rather than detergent (using ecoballs/ecoeggs doesn't invalidate any product guarantees however we find they really aren't good enough for washing nappies even at 60deg)

If your baby has any history of repeated rashing or skin sensitivity

If you have two or more babies using the same nappies

If you live in a commune or other "open" community (your baby will not become resistant to unfamiliar bugs)

If your baby is unwell

Petit Lulu Nappies insist on washing at 60deg.

The wash cycle should be the longest cycle you can find on your machine and not one of the economy quick washes. These are heavily soiled items so need a long deep wash. If you have the choice of cotton or synthetics on your machine, the cotton cycle should be used as it uses more water. If you have an "extra water" function on your machine please use it, modern washing machines are ULTRA water efficient which is generally great but when you're washing approx 15 nappies that hold 500ml each you need a lot of water to ensure they are thoroughly flushed through.

Detergent Dosage
Lots of people get very hung up on the amount of detergent they should use, in our experience people tend to over dose and forget to regularly run a maintenance cycle on their machine leading to detergent residue in their machines too. Our guide as a starting point is to read the packaging of your detergent and find the recommended dose for your water hardness and drum size and then use half to 3/4 of this recommended dose. You haven't got a full drum (see step 1) so a full dose of detergent is normally too much.
Using too much detergent can result in residue building up in the fabric which can cause sensitivity, damage to the nappies, smells and leaks. When your nappies come out of the machine your nappies should smell of nothing. If you can still smell detergent this is a sign you've used too much. If after washing they smell unclean this is a sign they've not been washed long enough, wrong dose of detergent used or too many in the machine (and or your machine needs a maintenance cycle run). The first thing we do when we have returns, especially faulty ones, is to sniff the nappies (glamorous job being a Nappy Lady). In the vast majority of times the "faulty" nappies reek of detergent and we can feel it built up on the fibres.

Bio V Non Vio
The reason we recommend non bio and not biological detergent is NOTHING to do with skin sensitivity but to do with protecting bamboo and cotton fabrics. Some biological detergents contain an enzyme called 'cellulase' which can have a degrading effect on cellulose fibres like bamboo and cotton and this can be particularly severe if combined with the levels of heat used when tumble drying. Using Biological can invalidate some manufacturers warranties.

How to use Biological Detergent Safely and Minimise Damage
If you have to use biological detergent as it's all you can find your Country or area or for any other reason then do the following!
1. Check your nappy warranty if the manufacturer specifially advises AGAINST biological detergent then you will need to accept you will invalidate your warranty and you're using bio at your own risk.
2. Check the ingredients VERY carefully. Choose a biological detergent WITHOUT CELLULASE as at this time cellulase is the enzyme identified as the main problem. This is easier said than done as many just list "enzymes" on the box rather than each specified enzyme. However some of the bigger brand names do list on the full ingredients and actual enzymes used on the box or online.
We don't supply a list of Cellulase free biological detergents for the simple reason manufactuers change their formulas.

Ecover
We DO NOT Recommend the use of Ecover with any cloth nappies as we find it frequently causes skin issues and problems with elastic in the nappies as it tends to build up on fibres very quickly.

Fabric Conditioner
Do not use fabric conditioner, as this will affect the absorbency over time.

Spin Speed
A washing machine with a higher speed spin will reduce the amount of drying needed. However, I would recommend that you keep the spin speed around 1000 revs, because higher than this may damage some nappies, or at least make the fabric go tatty. You will know from your own experience of washing your clothes how fierce your spin facility is!

Step 4. Drying Nappies
In general order of preference, these are the best ways to dry your nappies:

1. Outside on the line - the sun is a natural bleach.

2. Ceiling drying rack.

3. Airing cupboard.

4. In front of an Aga or other similar oven (or old fashioned stove).

5. Freestanding or overbath dryer - a dryer is best stood in a well-ventilated room such as a conservatory or bedroom, as bathrooms often have too damp an atmosphere to dry effectively.

6. Tumble drier - makes nappies feel nice and soft, but works out expensive and also shortens the life span of your nappies by taking out the pile gradually. You will need to remember to empty the filter regularly of all the fluff. Or you could give your nappies no more than 10 minutes in the tumble drier and then finish them off in one of the other ways listed, to get some of the softness without the cost. Other people swear by keeping the 10 minute tumble dry for the end of the drying period, rather than the beginning, but that is difficult to time. Tumble drying should be avoided for any waterproof PUL covers which includes all in ones. If you have no choice but to tumble dry make sure you only dry any bamboo fabrics or waterproof layers low. If you have all in ones

7. Near a raditoar - nappies will feel quite hard, but can be shaken out to soften them up a bit. Never dry directly on a radiator.

8. Terries and prefold can also be ironed dry - many shaped nappies cannot be, either because they are too thick, or they contain some material which should not be ironed. This option is bottom of the list because it involves the serious disadvantage of requiring some effort on your part! Never iron wraps.

Note that you should not dry any clothes in a room used by anyone with a sensitivity to house dust mites, as these love to breed in the warm air produced by damp clothing.

With washing, all nappies will get stiffer than they were when new, although it does help to live in a soft water area (eg Wales!). Shaped terries with a stretch agent (eg Motherease) in them or microfibre nappies such as the Teddy will tend not to go as hard as old fashioned terries. Bear in mind, however, that your baby will not feel the material directly against their bottom anyway, because there will be a liner on top. Also, as soon as baby wees, the whole thing softens up.Smart Bottoms washing instructions are found

Nappy Brands Specific Washing Instructions Charlie Bananas washing instructions are found here.
Baby Beehinds Washing Instructions are found here.
Bambino Mio's Washing Instructions are found here.
Bare and Boho washing instructions are found here.
Blueberry washing instructions are found here.
Bubblebubs washing instructions are here.
Bumgenius washing instructions are found here.
Charlie Bananas washing instructions are found here.
Close washing instructions are found here.
Disana care guides are found here.
Grovia washing instructions are found here.
Kangacare washing instructions are found here.
Little Lambs washing instructions are here.
Milovia washing instructions are found here.
Petit Lulu washing instructions are found here.
here.
Thirsties washing instructions are found here.
Totsbots Washing Instructions can be found here.

You'll find all the individual nappy brand warranties in more detail here. Ensure you double check this page before you start washing your nappies so you don't accidently void your warranty by using the wrong detergent or washing methods.
How Often to Change
During the day, every 2½ - 4 hours, depending on baby's age and how heavy a wetter they are, but always straight after a poo. At night, if you add extra absorbency, the baby can stay in the same nappy for 12 hours or more (unless they poo).

You will find that it is not necessary to use creams on a regular basis. We recommend cream just during the early weeks with a newborn and during teething. If baby does get nappy rash change more frequently and consider using cream or a suitable wash solution. A cup of honey and camomile tea (from teabags) makes a very effective and soothing antiseptic wash without chemicals or stinging. This has almost miraculous properties and is worth trying first if needed.
Nappy Rash
Despite the advertisers' claims, most rashing has nothing to do with wetness. Most babies are not bothered by a wet nappy at all, although some find it itchy when teething. Research shows that the type of nappy used is irrelevant as a cause of nappy rash, as this arises when stale urine comes into contact with the bacteria in poo, producing ammonia. A child using real nappies may be less likely to have nappy rash, simply because the parents are usually more aware of proper cleaning of the whole nappy area.

Important things to note: Always change nappy straight after a poo. Always clean the whole nappy area, not just the genitals. Some children will simply be more susceptible to rashing than others. Diet also affects it, so consider keeping a food diary if your child seems to be sensitive. During teething is when children are most likely to develop nappy rash, but a lot of this is because they are more susceptible to dietary factors - consider oranges, tomatoes and avocados in particular as likely suspects during this time. Use fleece liners to keep baby's bottom dry, to prevent soreness worsening. Change nappies more frequently if need be.

Note that not all rashes are nappy rash - if you are not sure, it is almost certainly NOT nappy rash. You will know it if/when you see it. A bit of redness may be an early sign, if left uncleaned, but is not in itself nappy rash. Consider other causes of rashing as well, such as sensitivity to washing powder, sweat rashes or thrush. Talk to your advisor if you have any concerns.
What to use for Cleaning Baby's Bottom
You can use cotton wool, packs of disposable wipes or reusable cloth wipes. Reusable cloth wipes are very environmentally friendly and cost nothing after initial purchase. They just go in the bucket with the dirty nappy. Also, unlike commercial wipes, you can control what you put on baby's bottom.

If not using commercial wipes, you may like to use the following recipe to add cleanser to your wipes or cotton wool. You can even put this solution into a spray bottle and use it when out and about:

1. Place a Camomile T-Bag in a suitable container; add boiling water and leave to cool.

2. Once cool, remove T-Bag and add approx. 1 tablespoon of Olive Oil.

3. Add 2-3 drops of Lavender Essential Oil (after 3months old)

4. Mix well and place washable wipes into container. You are aiming to put enough wipes in to soak up all the liquid, and leave them nice and moist for use, without being sopping wet (you can squeeze them out before using if too wet).

It is best to make up enough to last two to three days at a time. After use, place in nappy bucket. There is no need to hang out on line to dry, just smooth into a pile ready to use again. This solution is very soothing, and can also help with healing if your baby has any redness or nappy rash.
Top Tips

1. New nappies should be washed a couple of times before use as this improves absorbency. Never use fabric conditioner, as this reduces absorbency, and never soak or wash them in Vinegar or Bicarbonate of Soda, which can damage the fabric over time.

2. Rinse soiled nappies through, wring out and keep in the nappy bucket damp until ready to wash to help stop stains from setting

3. Wraps (covers) should not be soaked in the nappy bucket, as this can affect their waterproofing, but can be kept in there if dry pailing.

4. If you tumble dry your nappies for 10 minutes before air drying them, they will stay much softer without you adding much to the cost of laundering.

5. If you live in a hard water area, nappies will gradually become hard. It helps to keep your washing machine clean if you run a maintenance wash or 80 degree hot wash with no laundry every months. You can also wash the nappies without powder occasionally, to help to remove any build up of detergents.

6. Shake nappies out thoroughly before hanging to dry. This will help with both drying speed and softness.

7. When you put the wrap (cover pants) on, feel around the top and the legs to make sure it completely covers the nappy, otherwise the wet will wick out onto clothes.

8. Consider folding any inbuilt or additional boosters so they pad precisely where your child wees: at the front for boys, in the middle for girls.

9. When you undo a dirty nappy, hold the liner from the underside and wipe off as much poo as possible before moving onto cotton wool or wipes.

10. To avoid bulk for a newborn baby, use muslin squares instead of your main nappies. See the fold instructions on the last page.

11. Cheaper underclothes (eg Tescos) have a more generous cut over real nappies. Use a popper vest to stop the nappy from being dragged down by trouser waistbands etc. It is possible to purchase vest extenders which make it easier to fit vests around a cloth nappy if need be.

12. For a good stay dry layer and a larger poo catching area, go for a fleece liner - poo drops off into the toilet easily and you can use the liner as the main wipe. Ideal if baby is sensitive to wee, and also reduces staining through to the nappy or soiling onto it.

13. Some disposable paper liners can be washed and reused a few times, to save money.

14. You will need at least three cover pants in each size, to allow for one in the wash and another for accidents. It therefore makes sense to buy a cover pant that is adjustable over a reasonable range of sizes. If you use pad folded prefold nappies, you will normally need 5 covers at each size, to allow for messy wraps.

15. Babies do not tend to poo in their sleep, only when they wake, so if they go to bed with full bowels they will fill their nappy shortly after waking.

16. Some babies react to a particular powder, so you may need to experiment with brands. Be cautious if using Tee Tree oil as some children can be very sensitive to this, particularly when under 6 months of age.

Muslin Fold for Newborns
Fasten with a Nappi Nippa to give a compact fit. Folding the corners further than the centre in step 1 makes a smaller nappy which is just as tidy. Using a terry is more bulky, but more absorbent. The beauty of this fold is that even a 60cm terry can be folded down to a size small enough for a newborn, with all the fabric spread evenly.
If you have a Problem with your Nappy System...
Talk to The Nappy Lady! We may be able to advise you on where you are going wrong. Good cloth nappies should be more reliable than disposables, not less.

Leave a Reply and share your opinions!

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A Beginners Guide to Using Your Cloth Nappies

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45 Comments Sunday, 3 February 2019 Understanding Your Nappies Using real nappies is not hard, just different from using disposables. You need to bear in mind that a "cloth nappy" will usually comprise of a number of parts; the nappy itself provides the absorbency, whilst the outer wrap (cover) provides the waterproof layer.

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Neonatal care in hospital

Special care for babies is sometimes provided on the ordinary postnatal ward and sometimes in a specialist newborn (neonatal) area.

Having a baby in neonatal care can be worrying for parents, but the staff looking after your baby should make sure you receive all the information, communication and support you need.

Not all hospitals provide specialist neonatal services, so your baby may be transferred to another hospital if she or he needs special care.

Why babies need special care

Babies can be admitted to neonatal care for a number of reasons, including when they:

are born early - 1 baby in 13 is born early, and babies born before 34 weeks may need extra help with breathing, feeding and keeping warm

are very small and have a low birthweight

have an infection

have a mother who has diabetes

have jaundice

had a very difficult birth

are waiting for, or recovering from, complex surgery

Touching and holding your baby

The special care baby unit may seem strange and confusing at first, especially if your baby is in an incubator or on a breathing machine. There may also be tubes and wires attached to their face and body.

Ask the nurse to explain what everything is for and show you how you can be involved in your baby's care. You may be able to change your baby's nappy, wash them and change their clothing.

Once your baby's stable, you'll be able to hold her or him. The nurses will be able to help you take your baby out of the incubator and show you how to have skin-to-skin contact.

Your baby will benefit greatly from physical contact with you. You can talk to your baby as well - this can help both of you.

You should wash your hands carefully and dry them thoroughly before touching your baby.

Feeding

To begin with, your baby may be too small or too sick to feed themselves. You can express some of your breast milk, which can be given to your baby through a tube.

A fine tube is passed through his or her nose or mouth into the stomach. This won't hurt them.

Talk to a midwife at the hospital about how you can express breast milk for your baby. The hospital may have breast pumps you can use.

Breast milk has particular benefits, especially for sick or premature babies, as it's enriched with proteins (notably antibodies), fats and minerals.

If your baby isn't able to have your breast milk to begin with, the milk can be frozen and given to them when they're ready.

When you go home, you can express milk for the nurses to give while you're away. There's no need to worry about how much milk you produce - every bit helps your baby.

Incubators

Babies who are very small are nursed in incubators rather than cots to keep them warm. You can still have a lot of contact with your baby.

Some incubators have open tops, but if your baby's incubator doesn't, you can put your hands through the holes in the side of the incubator to stroke and touch them.

Newborn babies with jaundice

Jaundice in newborn babies is common because their livers aren't fully developed. Jaundice will make their skin and the whites of their eyes look a bit yellow.

Babies with severe jaundice may be treated with light therapy (phototherapy). The baby is undressed and put under a very bright light, usually with soft eye pads or a special box over their head to protect their eyes.

The special light helps break down the chemical that causes jaundice. It may be possible for your baby to have phototherapy by your bed in the postnatal ward so you don't have to be separated.

Light treatment may continue for several days, with breaks for feeds, before the jaundice clears up. Sometimes, if the jaundice gets worse, your baby may need a blood transfusion. This isn't common.

Some babies have jaundice because of liver disease and need different treatment. A blood test that checks for liver disease is done before phototherapy is started.

Find out more about how newborn jaundice is treated.

Babies with jaundice after 2 weeks

Many babies are jaundiced for up to 2 weeks after they're born, or 3 weeks in premature babies.

It's more common in breastfed babies and does no harm. It's not a reason to stop breastfeeding.

It's important to see your doctor within a day or two if your baby is still jaundiced after 2 weeks, especially if their poo is chalky white. This can indicate a liver problem.

A blood test will distinguish between jaundice that'll go away by itself, or jaundice that may need urgent treatment.

Babies with disabilities

If your baby is disabled, talk to people about how you feel, as well as about your baby's health and future.

Your GP, a doctor for newborn babies (neonatologist), a children's doctor (paediatrician) or your health visitor can all help you.

You can also contact the hospital Patient Advice and Liaison Service (PALS) or your social services department (through your local authority) for information about local organisations that may be able to help.

The organisations listed here can offer help and advice:

Talking to other parents with similar experiences can often help.

Worries and explanations

Hospital staff should explain what kind of treatment your baby is being given and why. If they don't tell you, ask them.

It's important that you understand what's happening so you can work together to make sure your baby gets the best possible care.

Some treatments need your consent to go ahead, and the doctors will discuss this with you.

It's natural to feel anxious if your baby needs special care. Talk over any fears or worries with the hospital staff. Hospitals often have their own counselling or support services, and a number of charities run support and advice services.

The consultant neonatologist or paediatrician should arrange to see you, but you can also ask for an appointment at any time if you wish.

The hospital social worker may be able to help with practical issues, such as travel costs or help with looking after children.

Read more information on serious conditions and special needs in children.

The charity Bliss has information and support for parents of babies being cared for in a neonatal unit.

You can find out more at:
Bliss: what to expect in hospital Bliss: you and your baby
healthtalk.org has video interviews and articles on women talking about their experiences of having a baby in special care.

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Special care for babies is sometimes provided on the ordinary postnatal ward and sometimes in a specialist newborn (neonatal) area. Having a baby in neonatal care can be worrying for parents, but the staff looking after your baby should make sure you receive all the information, communication and support you need.

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Special care baby unit (SCBU, SCU or low dependency) - Level 1

This is for babies who do not need intensive care. Often, this will be for babies born after 32 weeks' gestation.

Care can include:

Monitoring their breathing or heart rate

Giving them more oxygen

Treating low body temperature

Treating low blood sugar

Helping them feed, sometimes by using a tube

Helping babies who become unwell soon after birth

Sometimes, a baby might be admitted to a special care baby unit for phototherapy to treat jaundice. But sometimes, this condition is treated in transitional or postnatal care (see above).

Local neonatal unit (LNU) - Level 2

This is for babies who need a higher level of medical and nursing support. If your baby was, or will be, born between 27 and 31 weeks' gestation, you may be transferred to an LNU.

Care on an LNU might include:

Short-term intensive care (usually up to 48 hours)

Short-term ventilation, continuous positive airway pressure (called CPAP) or high flow therapy, for breathing support

Care during periods where their breathing pauses briefly, called 'apnoea' (pronounced ap-knee-ya)

Feeding through a drip in their vein (called parenteral nutrition)

Cooling treatment for babies who have had difficult births or are unwell soon after birth (before being transferred to a neonatal intensive care unit - see below)

Helping babies who become unwell soon after birth

Neonatal intensive care unit (NICU) - Level 3

This is for babies with the highest need for support lasting more than 48 hours. Often these babies will have been born before 28 weeks' gestation, or be very unwell after birth.

You might have been transferred to a different hospital which has a neonatal intensive care unit before your baby was born. This is usually because the staff feel your baby would benefit from this level of care, but that it is safer to transfer your baby before they are born.

Some of the reasons babies are cared for here are when they:

Need help with their breathing (called ventilation)

Need help with their heartbeat and blood pressure

Have a moderate to severe condition affecting their breathing (called respiratory distress)

Need longer-term feeding support through an intravenous (intra-venus) tube or general nutritional support

Need or have just had surgery - including cooling treatment for brain injuries

At a neonatal intensive care unit, all levels of care may also be given to babies from the local area.

Our friends at the Cambridge University Hospitals Trust and Rosie Maternity and Neonatal Voices Partnership have made a video about NICU, especially aimed at big brothers and sisters that helps to explain what NICU is.

I'm confused by the different levels of neonatal care

It can be confusing to understand your baby's level of care.

Sometimes babies might be treated in different types of units because their condition has changed. It might not be clear straight away what type of care your baby is getting.

For example, your baby could be in a neonatal intensive care unit, but getting special care. You can always ask the staff if you want more information about the level of care your baby is getting.

You might hear staff on the unit call the different levels of care by different names than we've used here. Have a look through our neonatal words for some other ways people talk about levels of care.

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It can be confusing to understand your baby's level of care. Here, we talk about the different levels of care neonatal units provide.

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Premature (or preterm) birth is when a baby is born before 37 weeks of pregnancy. If this happens, your baby may need special care and treatment.

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In October 2015, the novelist Francesca Segal met her 10-week premature twin daughters for the first time. The intensive care soundtrack was "a combination of control tower, server room and a busy canteen". Her doll-sized daughters were too fragile for clothes so she found them naked, curled face down in oval nests of towels. When she peered at their faces, she saw little cloth hats and white Velcro sunglasses, their noses and mouths obscured by breathing masks and feeding tubes. For a few more days, their faces remained "a secret known only to each other" and she was unable to touch them. "They are half-beings in the half-light and in an instant my heart shatters, and I become half a mother, twice."

This is the reality of early motherhood for 100,000 women in the UK each year and it's a story that, despite the recent plethora of literature about motherhood, has rarely been told by a British mother (in the US there's Vicki Forman's This Lovely Life). Segal is the right person to do it. She writes with delicate eloquence, combining passion and comic understatement so deftly that this feels the only way the book could have been written. Lyricism is undercut by everyday dialogue or WhatsApp messages and marshalled into a startlingly dramatic structure. Even if we know that the babies survive, there's something about the pacing that means we don't quite believe it during each moment of danger. Both babies develop life-threatening infections and one is diagnosed with necrotising enterocolitis (NEC), which has a survival rate of below 50%. I don't think I've turned the pages so urgently in a book about motherhood before.

When she's first admitted to hospital Segal is sure it will be fine because everything else in the past 35 years has been

The themes that emerge are universally urgent. Throughout, there are observations on the strengths and limitations of the NHS. The care in their London hospital is medically exemplary but emotionally so cold as to be almost cruel. Doctors are elusive and it takes days before Segal and her husband are given an explanation of what's to follow. She enters the room to find nurses pinning her baby down while a "longline" (a plastic tube threaded between the wrist vein and the heart) is installed. Though medical research suggests premature babies are sensitive to pain, in 2015 the hospital hadn't yet taken this on board and did the procedure without pain relief. Most worrying, perhaps, though also understandable in these underfunded times, is the decision to separate the twins when they're deemed ready to move to the local hospital because only one bed is ready. When they develop infections, Segal races across London from one potentially dying baby to another, without enough time to express enough milk, constantly missed by her children who can also be assumed to be missing each other. Nonetheless, these moments of institutional callousness are understood to be necessary within an imperfect but still monumentally generous system. And in the local hospital, Segal finds the kindness she has missed.

It's also a book about luck, and how misguided we are to take it for granted. When she's first admitted to hospital with blood pouring between her legs, Segal is convinced that it will be fine because everything else in the past 35 years has been. Gradually, she renegotiates her relationship with the gods, so that when it turns out her baby does not in fact have NEC she sees it as "another stroke of luck. I do not, not for one moment, take it for granted." This process of coming to understand provisionality and struggle takes place, crucially, in a community. Indeed, Segal's implicit argument is that communal kindness is as important as expensive, skilful but coldly administered medicine in making life livable, even in moments of medical crisis. The book is as much Segal's love letter to the solidarity of the hospital "milking shed" as to her daughters and husband. Here, as the milk drips from the women's breasts, they confide in each other and root for one another's children with what feels like genuine selflessness, possible because their sense of self has expanded to incorporate others.

"There has been no rivalry among the women of the milking shed, no cattiness," Segal writes; "only sisterhood, generosity, kindness." This might sound too good to be true, like her saintly husband, whom we only see being supportive and loving. But perhaps it is in fact possible. Perhaps innocent suffering does create saintliness in those who witness it, so that motherhood, friendship and marriage can be briefly unambivalent. Certainly this is why this book feels more hopeful than harrowing. I cried many times while reading it, more often because I was moved than sad. Segal has found a way to record love without sentimentality: love that enables the exhausted, underpaid nurses and the shattered, frightened mothers to survive.
* Mother Ship is published by Chatto & Windus (£14.99). To order a copy go to guardianbookshop.com or call 0330 333 6846. Free UK p&p over £15, online orders only. Phone orders min p&p of £1.99. Topics

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Mother Ship by Francesca Segal review - a moving story about motherhood

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In October 2015, the novelist Francesca Segal met her 10-week premature twin daughters for the first time. The intensive care soundtrack was "a combination of control tower, server room and a busy canteen". Her doll-sized daughters were too fragile for clothes so she found them naked, curled face down in oval nests of towels.

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How to cope and keep calm with a crying baby | Baby & toddler articles & support | NCT

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Keeping calm with a screaming baby is easier said than done. Tensions and emotions run high during those first few days, weeks and months. 

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Group B streptococcal (GBS) is a common bacteria that likes to live in the human gut and migrate down the rectum, vagina and sometimes to the urinary tract. Not everyone has GBS but even if you do, you might not know it; it can cause illnesses in people of all ages and sex, but most of the time it doesn't.

One group at particular risk of GBS, however, is newborn babies, who may pick up GBS from their mother's vaginal tract during childbirth. For newborns, GBS is a major cause of meningitis (infection of the lining of the brain and spinal cord), sepsis (blood infection) and pneumonia (lung infection).

Most early onset GBS disease (90%) occurs in the first 24 hours and up to a week following birth. It affects around 1 in 2,000 babies. Some become very sick and, while rare, around 1 in 17,000 die of it.

Around 10-30% of pregnant women are colonised with GBS, meaning the bacteria live in or on the woman's body without her necessarily feeling unwell.

It was once standard procedure in many Australian hospitals to administer intravenous antibiotics to such women early in labour in an effort to reduce risk to newborn babies.

However, other countries are pursing different approaches to attempt to reduce the disruption early exposure to antibiotics can cause to the newborn's microbiome.

Read more: Coronavirus while pregnant or giving birth: here's what you need to know

Two approaches to screening pregnant women for GBS

There are two approaches to GBS screening in pregnancy: universal screening and a risk-based strategy.

All women who are pregnant are recommended to have a urine test (early in pregnancy) which may pick up GBS. Universal screening involves taking a swab of the pregnant woman's vagina and around the anus (which women can do themselves) when they're around 36 weeks pregnant. Under the universal approach, all women who test positive to GBS are recommended to have intravenous antibiotics during labour to reduce the risk of the baby developing a GBS infection soon after birth.

A risk-based strategy means only giving antibiotics to women who test positive to GBS or have other high risk factors such as:

the labour that starts before 37 weeks

the baby has a low birth weight

membranes (water surrounding the baby) are broken for longer than 18-24 hours

the mother has had a baby previously sick with GBS

the mother has a high temperature during labour.

So which approach delivers better outcomes? Unfortunately, it's not yet possible to answer that question conclusively.

In the United Kingdom, Denmark, Netherlands and New Zealand universal screening is not recommended.

In the United States universal screening for GBS is recommended.

In Australia it's up to health providers and hospitals to make a decision with women on whether to test. But this can also be very confusing.

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GBS can come and go

The problem is that GBS can come and go. It may be present when a woman is screened late in pregnancy but not at the time of birth. And confirmed GBS sepsis (blood infection) cases in babies can occur in mothers who tested negative for GBS when screened earlier in pregnancy.

In short: sometimes GBS testing has meant women (and their newborns) who don't need antibiotics are getting them, while others who might benefit from antibiotics are missing out.

However, new rapid GBS screening takes around two hours to get the result, meaning women can be tested when they go into labour or their waters break. Unfortunately, these rapid tests are not yet available in all Australian hospitals.

What does the evidence say about antibiotics for GBS?

If antibiotics are given more than four hours before the birth, it prevents GBS in the baby in 91% of cases.

But antibiotics prevent GBS in babies in less than 50% of cases if given fewer than four hours before the birth.

And antibiotics during labour make no difference when it comes to reducing late-onset GBS disease (one week or more following birth).

A review of four randomised controlled trials involving 852 women found giving antibiotics to women who tested positive for GBS reduces the incidence of early onset GBS disease in babies, though not death from GBS infection or other bacterial infections.

However, there were some problems with these studies, including small numbers and poor reporting which makes these results unreliable.

This means automatically giving antibiotics to all women during labour is not supported by conclusive high-level evidence; however, it is widely recommended if GBS has been found.

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What about the impact of antibiotics on the microbiome?

For a newborn baby, the first super dose of microbes comes during the birth through the vagina, which contains around 200-300 types of bacteria.

These bacteria help seed the new baby's microbiome, shaping its health and setting up an effective defence shield for infections.

The microbiome of the vagina changes through pregnancy. Halfway through pregnancy, hormonal shifts begin to stockpile glycogen (bacteria's favourite food). As the bacteria turn this glycogen into lactic acid the PH level of the vagina lowers (more acid like) and this discourages harmful bacteria like GBS from growing.

As the baby passes through the vagina, it is coated in and ingests this protective bacteria (this process doesn't occur with caesarean section). When the baby breastfeeds, they ingest components that are only found in breastmilk that feed the good bacteria and protect the baby.

Disturbance of this vulnerable early seeding of the microbiome with antibiotic use during labour and birth for GBS alter the balance of microbes in the baby's intestines.

Several inflammatory conditions, including obesity, have also been linked to this.

Weighing all this information up means a clear recommended pathway for GBS detection and treatment still evades us.

The most important thing for new parents to know is how to look out for an unwell baby and get help quickly. Signs of GBS infection include:

temperature that's too high or low (get a thermometer)

poor feeding

irritability

sleeping more than normal or not moving much

rapid or noisy breathing (grunting or moaning)

skin colour changes (including looking blotchy)

any significant change in behaviour that does not resolve.

The quicker the treatment, the better the outcome. Breastfeeding can't pass GBS infection to your baby and, in fact, is really important to help protect your baby from infections.

The MothersBabies Study

Our MothersBabies Study is investigating how the microbiome affects a woman's health before pregnancy, during pregnancy, and in the first year of their child's life.

This study can't be conducted without the help of the community, so please get in touch if you want to know more or are interested in being included. You just need to be living in NSW and planning to get pregnant in the next 12 months. Email mothersbabies@unsw.edu.au to register your interest or find out more.

Read more: Coronavirus with a baby: what you need to know to prepare and respond
Correction: This article was corrected to change "A risk-based strategy means only giving antibiotics to women who test positive to GBS and have other high risk factors" to "A risk-based strategy means only giving antibiotics to women who test positive to GBS or have other high risk factors such as". We also clarified when the urine test is done and that confirmed GBS sepsis can occur in babies in mothers who tested negative for GBS earlier in pregnancy.

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Group B strep and having a baby: what pregnant women need to know

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Group B streptococcal (GBS) is a common bacteria that likes to live in the human gut and migrate down the rectum, vagina and sometimes to the urinary tract. Not everyone has GBS but even if you do, you might not know it; it can cause illnesses in people of all ages and sex, but most of the time it doesn't.

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Becoming a dad - advice for new dads, including what to expect from pregnancy, birth and life with a new baby

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Yoga with Rebecca a.k.a The Yoga Midwife

Rebecca, a.k.a @theyogamidwife, is an experienced and practising midwife and yoga teacher, who is expecting her own baby this summer! She shares her pregnancy journey, along with tips and pregnancy information in her blog posts. On this page, Rebecca has given us an intro into some simple poses you can try at home. These particularly focus on easing pregnancy discomforts, building strength and confidence, as well as enhancing relaxation.

Why yoga?

A study, funded by Tommy's, showed that yoga can reduce antenatal stress hormone levels and anxiety. By combining breathing exercises, mindfulness techniques and physical postures, just one session of yoga was found to reduce self-reported anxiety by a third! And stress hormone levels by 14%! Unlike some other complementary therapies that have been tested in pregnant women, the effects of yoga were found to last long after the activity was completed. Not only that but yoga has long been known to help women stay calm in pregnancy and labour. It helps to improve sleep, and the breathing techniques you use in yoga can help you prepare for giving birth, to breathe steadily through your contractions.

Studies have also identified that pregnancy yoga improves vaginal birth, decreases premature delivery, and shortens the labour duration.

Is it safe to do yoga?

Yoga that has been properly adapted for your stage of pregnancy is safe for you and your baby. If you're new to yoga, look for a class that is specific for pregnant women. If you've been doing yoga for a while, it's important to seek advice from your yoga teacher or midwife, to make sure that any poses you do are safe for you and your baby. It is best to focus on improving your technique during pregnancy - rather than trying new and advanced postures.

As your bump gets bigger, your centre of gravity will shift, meaning you may lose balance more easily. So try to move slowly when practising yoga and for any postures that require greater balance, try to use support if you need it.

Styles of yoga vary, if you start practising during pregnancy, you are likely to be directed towards slower paced styles, such as Hatha. It's important to avoid heated yoga, such as Bikram, during pregnancy. You can read our guidance on exercise during pregnancy to find out more information about preventing overheating.

Yoga and your pelvic floor

Yoga poses will work with your breath, to both strengthen, stretch and relax the pelvic floor. Strengthening the pelvic floor is crucial in order to help ease your baby out during labour. It provides resistance to the head so it can turn and make its way through the pelvis, much like a key turning in a lock. It is also important to know how to relax these layers of muscle, so that your baby can pass through during birth. There are several methods of yoga breath work that help with this.

Drawing attention to your pelvic floor is essential during pregnancy, birth and beyond to make sure you are able to do pelvic floor exercises. During your pregnancy, your pelvic floor muscles will loosen due to hormonal changes in your body. This loosening, along with your growing baby pressing on your bladder, may cause you to leak urine when you cough, laugh, sneeze or exercise. Doing pelvic floor exercises will strengthen these muscles and help you control any accidents and also help you to recover faster after birth.

Follow Rebecca's blog posts and Instagram account for more pregnancy yoga!

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Pregnancy yoga at home with The Yoga Midwife

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Yoga is a great way to stay active and look after your wellbeing during and after pregnancy. There are some brilliant at tutorials you can access online, just make sure they are specialised for pregnancy. The Yoga Midwife takes us through some simple poses to get you started.

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Midwife

Whatever type of pregnancy you have, you'll see your midwife a fair few times. A midwife (or a number of midwives) will take care of you when you're pregnant, during labour and after your baby arrives. Then they'll hand you over to your next pregnancy guardian: your health visitor.

Health visitor

Your health visitor will first pop along to your home to introduce themselves when you're pregnant (NHS, 2015a). Put the kettle on because maybe they'll stay for a drink, chat through some information and tell you about the postnatal clinics that'll weigh your baby when they're born (NHS 2015a; Scottish Government, 2015; NHS Wales, 2016). Then you won't see them again for a little while - until your midwife discharges you after your baby is born.

GP

While you're pregnant, you'll still see your GP for anything non-baby related. If your baby was born at home then your GP may conduct the newborn (NIPE) check (NHS, 2015b).

Your GP will also be involved when they give you your six-week check after you have the baby. This check involves talk through how you are feeling physically and mentally, checking any stitches or caesarean scar and talking about issues like contraception (NHS, 2016a).

Sonographer

Ah, the emotional part. The sonographer will carry out the scan or scans that you'll be offered during pregnancy to see how your baby is growing and developing.

Dietician

Not one that most people will see but they may come in if you have gestational or normal diabetes. If so, they'll give you support with healthy eating during your pregnancy (NHS, 2015a).

Anaesthetist

If you have an epidural during labour, the anaesthetist will give the injection (NHS, 2015a). They'll also give the pain relief during other types of birth, including caesareans, too (NHS, 2015a).

Neonatal nurses

If your baby needs to go to special care, specialist neonatal nurses will look after them (NHS, 2015c).

Obstetrician

An obstetrician is a doctor who specialises in complicated pregnancies and childbirth (NHS, 2015a). If your midwife thinks it's needed, they will refer you to an obstetrician for more tests or treatment. Obstetricians also take charge of forceps or ventouse births as well as caesareans (NHS, 2015a).

Obstetric or pregnancy physiotherapist

Joint or muscle pain can be a common complaint in pregnancy and, if you're suffering, your midwife might refer you to an obstetric physiotherapist (NHS, 2015a). After the birth, pregnancy physiotherapists can support women with continence problems too (NHS, 2016b).

Paediatrician/neonatologist

A doctor who specialises in babies and children is a paediatrician. A doctor who specialises in the first six weeks of a child's life is a neonatologist (NHS, 2015c). They may be present at more complicated births, and they will lead the care that takes place in the neonatal unit too (NHS, 2015c).

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.

NHS. (2015a) Antenatal support, meet the team. Available from: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/antenatal-team-midwife-obstetrician-pregnant.aspx [Accessed 19th September 2017]

NHS. (2015b) Newborn physical examination. Available from: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/newborn-physical-exam.aspx [Accessed 19th September 2017]

NHS. (2015c) Special care: ill or premature babies. Available from: http://www.nhs.uk/Conditions/Incontinence-urinary/Pages/Treatment.aspx [Accessed 19th September 2017]

NHS. (2016a) Your six-week postnatal check. Available from: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/postnatal-check.aspx [Accessed 19th September 2017]

NHS. (2016b) Urinary incontinence - non-surgical treatment. Available from: http://www.nhs.uk/Conditions/Incontinence-urinary/Pages/Treatment.aspx [Accessed 19th September 2017]

NHS Wales. (2016) An overview of the health child Wales programme. Available from: http://gov.wales/docs/dhss/publications/160926healthy-childrenen.pdf [Accessed 19th September 2017]

Scottish Government. (2015) Universal Health Visiting Pathway in Scotland. Available from: http://www.gov.scot/Publications/2015/10/9697/1 [Accessed 19th September 2017]

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Health professionals you might see during your pregnancy | Pregnancy articles & support | NCT

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For most women, pregnancy healthcare is a total unknown. Here's a handy guide to who you'll be chatting to for the next nine months...

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Find out what to expect from every week of your pregnancy.

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Group B strep is a type of bacteria called streptococcal bacteria.

It's very common in both men and women and usually lives in the bottom (rectum) or vagina. It affects 2 to 4 women in 10.

Group B strep is normally harmless and most people will not realise they have it.

It's usually only a problem if it affects:

pregnant woman - it could spread to the baby

young babies - it can make them very ill

elderly people or those who are already very ill - it can cause repeated or serious infections

This page focuses on group B strep in pregnancy and babies.

Group B strep in pregnancy

Group B strep is common in pregnant women and rarely causes any problems.

It's not routinely tested for, but may be found during tests carried out for another reason, such as a urine test or vaginal swab.

Risks in pregnancy

If you have group B strep while you're pregnant:

your baby will usually be healthy

there's a small risk it could spread to your baby during labour and make them ill - this happens in about 1 in 1,750 pregnancies

there's an extremely small risk you could miscarry or lose your baby

What to do if you're worried

If you're worried about group B strep, speak to your midwife or GP for advice.

Talk to them about the risks to your baby and ask their advice about whether to get tested.

Routine testing is not currently recommended and tests are rarely done on the NHS, but you can pay for one privately.
Find out more about getting tested for group B strep on the Group B Strep Support website
What happens if you have group B strep

If tests find group B strep, or you've had a baby that's been affected by it before, you may need extra care and treatment.

You may be advised to:

speak to your midwife about your birth plan - they may recommend giving birth in hospital

contact your midwife as soon as you go into labour or your waters break

have antibiotics into a vein during labour - this can significantly reduce the risk of your baby getting ill

stay in hospital for at least 12 hours after giving birth so your baby can be monitored - this is not always necessary

Group B strep in babies

If you had group B strep during pregnancy, there's a small risk it could spread to your baby and make them very ill.

If this happens, it's usually soon after they're born. Your baby may be monitored in hospital for up to 12 hours to check for any problems.

They'll be given antibiotics into a vein if they develop symptoms.

What to look for after leaving hospital

Occasionally, symptoms of a group B strep infection can develop up to 3 months after birth.

Call 999 or go to A&E if your baby gets any of these symptoms:

being floppy or unresponsive

grunting when breathing, or working hard to breath when you look at their chest or stomach

very fast or slow breathing

a very fast or slow heart rate

an unusually high or low temperature

changes in their skin colour or blotchy skin

not feeding well or vomiting milk up

an unusually fast or slow heart rate

They may need treatment with antibiotics in hospital immediately.

Risks in babies

Most babies with a group B strep infection make a full recovery if treated.

Some babies may develop serious problems like sepsis or meningitis.

This can cause lasting problems like hearing loss or loss of vision. Sometimes it can be fatal.

More information

Page last reviewed: 12 March 2021
Next review due: 12 March 2024

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Group B strep is a type of bacteria called streptococcal bacteria. It's very common in both men and women and usually lives in the bottom (rectum) or vagina. It affects 2 to 4 women in 10. Group B strep is normally harmless and most people will not realise they have it.

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Your body has a great deal to do during pregnancy. Sometimes the changes taking place can cause irritation or discomfort, and sometimes you may be concerned.

There's rarely any need for alarm, but you should mention anything that's worrying you to your maternity team.

This page offers information on some of the more common problems. You can find links to other common pregnancy problems at the bottom of this page.

Constipation in pregnancy

The hormonal changes in your body may cause you to become constipated very early on in your pregnancy.

Avoiding constipation

To help prevent constipation, you can:

eat foods that are high in fibre, such as wholemeal breads and cereals, fruit and vegetables, and pulses such as beans and lentils - read more about having a healthy diet in pregnancy

exercise regularly to keep your muscles toned - read more about exercise in pregnancy

drink plenty of water

avoid iron supplements, which can make you constipated - ask your doctor if you can either manage without them or change to a different type

You can read more about constipation, including symptoms and treatment.

Cramp in pregnancy

Cramp is a sudden, sharp pain, usually in your calf muscles or feet. It's most common at night. Nobody really knows why it happens, but there are some ideas about causes of cramp and why it can occur in pregnancy.

Avoiding cramp

Regular gentle exercise in pregnancy, particularly ankle and leg movements, will improve your circulation and may help prevent cramp. Try these foot exercises:

bend and stretch your foot vigorously up and down 30 times

rotate your foot 8 times one way and 8 times the other way

repeat with the other foot

How to ease cramp

It usually helps if you pull your toes hard up towards your ankle or rub the muscle hard.

Feeling faint in pregnancy

Pregnant women can often feel faint. This is due to hormonal changes. Fainting happens if your brain is not getting enough blood and, therefore, not enough oxygen.

You are most likely to feel faint if you stand up too quickly from a chair or out of a bath, but it can also happen when you are lying on your back. Read more about the causes of fainting.

Avoiding feeling faint

Here are some tips to help avoid feeling faint:

try to get up slowly after sitting or lying down

if you feel faint when standing still, find a seat quickly and the faintness should pass - if it doesn't, lie down on your side

if you feel faint while lying on your back, turn onto your side

It's better not to lie flat on your back in later pregnancy or during labour. You should avoid going to sleep on your back after 28 weeks as it has been linked to a higher risk of stillbirth.

Find out about:

Feeling hot in pregnancy

You're likely to feel warmer than usual during pregnancy. This is due to hormonal changes and an increase in blood supply to the skin. You're also likely to sweat more.

It can help if you:

wear loose clothing made of natural fibres, as these are more absorbent and breathable than synthetic fibres

keep your room cool - you could use an electric fan

wash frequently to help you feel fresh

Incontinence in pregnancy

Incontinence is a common problem during and after pregnancy. Pregnant women are sometimes unable to prevent a sudden spurt of pee or a small leak when they cough, laugh, sneeze, move suddenly or just get up from a sitting position.

This may be temporary, because the pelvic floor muscles (the muscles around the bladder) relax slightly to prepare for the baby's delivery.

You can find out more about:

When to get help

In many cases, incontinence is curable. If you have a problem, talk to your midwife, doctor or health visitor.

Peeing a lot in pregnancy

Needing to pee a lot often starts in early pregnancy and sometimes continues until the baby is born. In later pregnancy, it's caused by the baby's head pressing on your bladder.

How to reduce the need to pee

If you find you need to get up in the night to pee, try cutting out drinks in the late evening. However, make sure you drink plenty of non-alcoholic, caffeine-free drinks during the day.

Later in pregnancy, some women find it helps to rock backwards and forwards while they're on the toilet. This lessens the pressure of the womb on the bladder so you can empty it properly.

When to get help

If you have any pain while peeing or you pass any blood in your pee, you may have a urine infection, which will need treatment.

Drink plenty of water to dilute your pee and reduce pain. You should contact your GP within 24 hours of noticing these symptoms. Read more about symptoms and treatment of urinary infections.

Don't take any medicines without asking your midwife, doctor or pharmacist whether they're safe in pregnancy.

Skin and hair changes in pregnancy

Hormonal changes taking place in pregnancy will make your nipples and the area around them go darker. Your skin colour may also darken a little, either in patches or all over.

Birthmarks, moles and freckles may also darken. Some women develop a dark line down the middle of their stomach. These changes will gradually fade after the baby is born, although your nipples may remain a little darker.

If you sunbathe while pregnant, you may find you burn more easily. Protect your skin with a high-factor sunscreen and don't stay in the sun for a long time. Read more about keeping skin safe in the sun.

Hair growth can also increase in pregnancy, and your hair may be greasier. After the baby is born, it may seem as if you're losing a lot of hair, but you're just losing the extra hair you grew in pregnancy.

Varicose veins in pregnancy

Varicose veins are veins that have become swollen. They can be uncomfortable but aren't harmful. They most commonly affect leg veins.

You can also get varicose veins in the vaginal opening (vulva), although these usually get better after the birth.

If you have varicose veins, you should:

avoid standing for long periods of time

try not to sit with your legs crossed

try not to put on too much weight, as this increases the pressure

sit with your legs up as often as you can to ease the discomfort

try compression tights, which you can buy at most pharmacies - they won't prevent varicose veins but can ease the symptoms

try sleeping with your legs higher than the rest of your body - use pillows under your ankles or put books under the foot of your bed

do foot and other antenatal exercises, such as walking and swimming, which will help your circulation

Try these foot exercises:

bend and stretch your foot up and down 30 times

rotate your foot 8 times one way and 8 times the other

repeat with the other foot

Read more about preventing varicose veins.

Other common problems

Other common health problems in pregnancy include:

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Your body has a great deal to do during pregnancy. Sometimes the changes taking place can cause irritation or discomfort, and sometimes you may be concerned. There's rarely any need for alarm, but you should mention anything that's worrying you to your maternity team.

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Whatever you want to know about being pregnant, from early pregnancy signs to which prenatal vitamins you should take, you should find it here. We're here to give you the essential guide and lots of free tools for having a healthy, happy baby..

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Whatever you want to know about being pregnant, from early pregnancy signs to which prenatal vitamins you should take, you should find it here. We're here to give you the essential guide and lots of free tools for having a healthy, happy baby..

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Barnet Birth Centre is situated on the first floor of the maternity building at Barnet Hospital and offers a range of modern facilities for women and their families. We have:

five birthing suites with private ensuite facilities

three postnatal care rooms with shower and toilet

three birthing pools for you to labour/birth in

a kitchen area.

If complications occur in your labour or you require an epidural for pain relief, you will be transferred to our consultant-led labour ward on the floor below.

Take a look at photos of the birth centre.

Tour our maternity unit. - Book now

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Barnet Birth Centre is situated on the first floor of the maternity building at Barnet Hospital and offers a range of modern facilities for women and their families. We have: five birthing suites with private ensuite facilities three postnatal care rooms with shower and toilet three birthing pools for you to labour/birth in a kitchen area.

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Welcome to the Diamond Jubilee Maternity Unit, we hope that your time in our care will be as happy and as comfortable as possible.

The Lister's Diamond Jubilee Maternity Unit opened in October 2011 and sees over 5,500 babies born every year. Our aim is to assist you to have a safe pregnancy and a healthy happy baby.

Early bird referral

Organising your pregnancy care early has benefits for you and your baby. To do this, please visit our early bird referral page and complete the online form. Once we receive this form we will send you your appointment to see a midwife within 10 working days.

Screening leaflet

Before you come to your first appointment, it is important that you read the screening leaflet as this contains information about screening tests which are available to you during your pregnancy. The midwife will discuss this further when you come for your first appointment.

Your antenatal care

In this part of our website, we've provided you with the following information:

Antenatal care

Health and wellbeing in pregnancy

Birth choices

Community midwives

Events and tours

Antenatal classes

Labour and birth

As you prepare for your labour and the birth of your baby, we've brought together a range of information that we hope you'll find helpful:

About labour

Preparation for labour

Encouraging labour over 37 weeks

When to come into hospital

Breast feeding

Birth afterthoughts

Our facilities

In considering the facilities we have to offer here in the Lister's Diamond Jubilee Maternity Unit, these pages have been set up to help you understand them:

Staying in hospital

Midwife-led unit

Consultant-led unit

Gloucester ward

Dacre ward

Amenity rooms

Day assessment unit/triage

Specialist services

Specialist services

Here at the Diamond Jubilee Maternity Unit, our team provides some specialist services for pregnant women and their babies:

Fetal medicine

Neonatal care

Multiple pregnancy service

Enhanced maternity services

Our enhanced maternity service

Welcome to the Diamond Jubilee Maternity Unit at the Lister Hospital in Stevenage. We are proud to offer women and their families a range of enhanced maternity services, delivered by our experienced and compassionate midwives. The services we provide are in addition to those everyone is offered through the NHS.

Our services

Scans

Hypnobirthing

Active birth workshop

Post-date complementary therapy clinic

Non-invasive prenatal testing

You can choose to have your baby at home, in our midwife-led unit, or in the consultant-led unit that provides care for women with more complicated pregnancies.

Currently we have five birthing pools in the maternity unit that may be used for labour and/or birth, including one in our consultant-led unit.

Private scans
Private ultrasound scans for reassurance:
We run a Tuesday evening clinic from 5.30-7.30pm which is staffed by our sonographers to offer scans from 6 weeks to term, to supplement your NHS scans. These scans can be tailored to suit your individual requirements, whether that be reassurance about the health of the pregnancy, your baby's growth or an opportunity to see baby again, using the same standards and protocols adhered to at routine scans.
Pricing list:
2D scans: £80

4D scans: £100 (24- 32 weeks)

You can book these through the private patients' department via:

01438 288036 or 01438 286646

or by emailing privatepatients.enh-tr1@nhs.net

Covid-19 guidelines

Following easing of restrictions, Lister Hospital has returned to pre-pandemic support levels for women and people in our care. The following is now in place:

Two named birthing partners are able to attend throughout the birthing process once in established labour or in a private area onour consultant-led unit (CLU) and midwife-led unit (MLU).

Women can be accompanied by one nominated birth partner when admitted to the Dacre ward at Lister Hospital's Diamond Jubilee Maternity Unit for an elective caesarean section, or when admitted for induction of labour up until 9pm in the evening.

One named adult support partner can attend all other assessments, scans or prenatal appointments. (Where required partners may be requested to wait in alternative wait areas until called through.)

Women can be joined on the antenatal (Dacre) ward between 9am and 9pm, and postnatal (Gloucester) ward between 10am and 8pm at Lister Hospital's Diamond Jubilee Maternity Unit by one nominated birth partner.

No one else, including children, are able to attend at any time, until further notice.

Unfortunately we cannot offer overnight stays for birth partners (between 9pm and 9am) as our inpatient facilities are not suitable for this. This is a permanent situation and is not related to Covid-19.

You can read more information on our Covid-19 maternity restrictions page which explains in what settings your nominated partner can attend.

You can also find out more about our Covid-19 maternity restrictions by reading our frequently asked questions page. You may need to refresh the page to see the latest information.

If you have read these, but have further questions which haven't been answered - please contact your community midwife.

Feedback

We have had positive feedback from mothers using the services, including from one mother:

"From the moment I was admitted until the time that my baby and I were discharged, the staff at Lister hospital were absolutely amazing. The midwives that assisted me in particular were wonderful, professional and extremely supportive."

If you would like to give birth at the Diamond Jubilee Maternity Unit or would like some help to choose where to give birth, take a look at our virtual tour. You can also book directly with us by using the online early Bird Referral booking form.

The Ockenden review

We understand that you may have concerns following the publication of the review of hospital services at Shrewsbury and Telford (known as the Ockenden review). However, please be assured we are committed to providing safe birthing services, regardless of where you birth your baby.

Our Trust is part of the Hertfordshire and West Essex Local Maternity and Neonatal System which continues to review, improve and expand on current services and practices.

We continue to review activity levels daily to ensure safe staffing levels, as the safety of you and your baby remains our top priority.

Our chief nurse, director of maternity and a representative from the Lister Maternity Voices Partnership have been speaking about what this means in the YouTube video below.

If you wish to provide feedback, please contact our Patient Advice Liaison Service (details can be found on the maternity contacts page of this website) or the Lister Maternity Voices Partnership.

If you have any individual questions regarding your care, please speak with your midwife or maternity team.

Maternity and perinatal audit

The Trust is taking part in the National Maternity and Perinatal Audit (NMPA). The aim of the NMPA is to study how mothers and babies are cared for in maternity units across England, Scotland and Wales. It will make it easier for units to monitor the care they provide. The audit will include information about all mothers who have a baby after 1 April 2014.

Visit www.maternityaudit.org.uk for more information.

National safety thermometer audit programme

The hospital and community midwifery teams participate in the national safety thermometer audit programme. This is a snapshot audit carried out on one day each month looking at harms within maternity care. This data helps us to continually review and improve our services. Click here to view our maternity safety thermometer data.

Lister Maternity Voices Partnership

The Lister Maternity Voices Partnership group listen to, and seek out, the voices of women, families and carers using maternity services, enabling people from diverse communities to have a voice. The group includes a combination of service users, hospital staff, commissioning groups, GPs and volunteers and they hold regular meetings locally. Visit the Lister Maternity Voices Facebook page to find out more.

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Maternity unit - East and North Hertfordshire NHS Trust

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Welcome to the Diamond Jubilee Maternity Unit, we hope that your time in our care will be as happy and as comfortable as possible. The Lister's Diamond Jubilee Maternity Unit opened in October 2011 and sees over 5,500 babies born every year. Our aim is to assist you to have a safe pregnancy and a healthy happy baby.

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Maternity

Welcome to our maternity service at The Princess Alexandra Hospital NHS Trust (PAHT). We help to deliver more than 4,000 babies a year. We are very proud of our service and we are committed to providing high quality maternity care.

We provide care at The Princess Alexandra Hospital, St Margaret's Hospital, Epping, and in the community to women who live in west Essex and east Hertfordshire, and we also welcome women from outside these areas.

Our team will introduce themselves to you and they also wear an identification badge - please ask if you are unsure of their names or roles.

We look forward to meeting you.

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Maternity Welcome to our maternity service at The Princess Alexandra Hospital NHS Trust (PAHT). We help to deliver more than 4,000 babies a year. We are very proud of our service and we are committed to providing high quality maternity care.

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We'd love to show you how your support is helping LGBTQ+ people everywhere to thrive. We need your consent to keep you up to date with our campaigns and events, and what you can do to help make life better for LGBTQ+ people.

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At Stonewall, we stand for lesbian, gay, bi, trans, queer, questioning and ace (LGBTQ+) people everywhere. We imagine a world where all LGBTQ+ people are free to be ourselves and can live our lives to the full.

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In vitro fertilisation (IVF) is one of several techniques available to help people with fertility problems have a baby.
During IVF, an egg is removed from the woman's ovaries and fertilised with sperm in a laboratory.

The fertilised egg, called an embryo, is then returned to the woman's womb to grow and develop.

It can be carried out using your eggs and your partner's sperm, or eggs and sperm from donors.

Who can have IVF?

The National Institute for Health and Care Excellence (NICE) fertility guidelines make recommendations about who should have access to IVF treatment on the NHS in England and Wales.

These guidelines recommended that IVF should be offered to women under the age of 43 who have been trying to get pregnant through regular unprotected sex for 2 years, or who have had 12 cycles of artificial insemination.

However, the final decision about who can have NHS-funded IVF in England is made by local clinical commissioning groups (CCGs), and their criteria may be stricter than those recommended by NICE.

If you're not eligible for NHS treatment, or you decide to pay for IVF, you can have treatment at a private clinic. Costs vary, but 1 cycle of treatment may cost up to £5,000 or more.

Read more about the availability of IVF.

Speaking to your GP about IVF

If you're having trouble getting pregnant, you should start by speaking to your GP. They can advise on how to improve your chances of having a baby.

If these measures don't work, your GP can refer you to a fertility specialist for a treatment such as IVF.

Read more about getting started with IVF.

What happens during IVF

IVF involves 6 main stages:

1. suppressing your natural cycle - the menstrual cycle is suppressed with medication

2. boosting your egg supply - medication is used to encourage the ovaries to produce more eggs than usual

3. monitoring your progress and maturing your eggs - an ultrasound scan is carried out to check the development of the eggs, and medication is used to help them mature

4. collecting the eggs - a needle is inserted into the ovaries, via the vagina, to remove the eggs

5. fertilising the eggs - the eggs are mixed with the sperm for a few days to allow them to be fertilised

6. transferring the embryo(s) - 1 or 2 fertilised eggs (embryos) are placed into the womb

Once the embryo(s) has been transferred into your womb, you'll need to wait 2 weeks before taking a pregnancy test to see if the treatment has worked.

Read more about what happens during IVF.

Chances of success

The success rate of IVF depends on the age of the woman undergoing treatment, as well as the cause of the infertility (if it's known).

Younger women are more likely to have a successful pregnancy. IVF isn't usually recommended for women over the age of 42 because the chances of a successful pregnancy are thought to be too low.

Between 2014 and 2016 the percentage of IVF treatments that resulted in a live birth was:

29% for women under 35

23% for women aged 35 to 37

15% for women aged 38 to 39

9% for women aged 40 to 42

3% for women aged 43 to 44

2% for women aged over 44

These figures are for women using their own eggs and their partner's sperm, using the per embryo transferred measure.

The Human Fertilisation and Embryo Authority (HFEA) has more information on in vitro fertilisation (IVF), including the latest success rates.

Maintaining a healthy weight and avoiding alcohol, smoking and caffeine during treatment may improve your chances of having a baby with IVF.

What are the risks?

IVF doesn't always result in pregnancy, and it can be both physically and emotionally demanding. You should be offered counselling to help you through the process.

There are also a number of health risks involved, including:

side effects from the medications used during treatment, such as hot flushes and headaches

multiple births (such as twins or triplets) - this can be dangerous for both the mother and the children

an ectopic pregnancy - where the embryo implants in the fallopian tubes, rather than in the womb

ovarian hyperstimulation syndrome (OHSS) - where too many eggs develop in the ovaries

Read more about support available during and after IVF and the risks of IVF.

Community content from HealthUnlocked

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In vitro fertilisation (IVF) is one of several techniques available to help people with fertility problems have a baby. During IVF, an egg is removed from the woman's ovaries and fertilised with sperm in a laboratory. The fertilised egg, called an embryo, is then returned to the woman's womb to grow and develop.

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A report out this week from a Danish hospital claims that if you're pregnant with an IVF, ICSI or other assisted conception baby, then you're four times as likely to have a stillbirth.

It makes alarming reading and my worry is that it will cause unnecessary stress to many IVF and ICSI patients who have already been through enough just to get pregnant in the first place.

I'd like to give some reassurance to my patients and those going through IVF right now at other hospitals and medical centres. Before you get too concerned, please bear in mind that this report needs to be taken into context.

The report shows that the risk of stillbirth after IVF, ICSI or other assisted conception method is still extremely low - 16.2 per thousand. The majority of people who have babies through IVF or ICSI go on to have healthy babies.

It also showed that the risk of stillbirth cannot be attributed to your infertility directly. The study showed that the risk was the same for fertile couples who got pregnant within a year and those who took longer. This indicates that the increased risk isn't down to infertility but possibly other as yet unexplained factors.

What this does alert us to is that more studies need to be carried out. I agree with Peter Baude, the head of women's health at Kings College London, Guys, Kings and St Thomas' hospitals, who said that the question of whether an IVF, or ICSI pregnancy carries a more increased risk of stillbirth needs to examined further, with a higher sample of women.

The Danish study sample was small - it in fact represented only 7 per cent of the babies born in the UK in just one year. If any of our patients have any concerns, please feel free to contact us or call in to see us. We'd be more than happy to put your mind at rest.

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Stillbirth study - Are IVF babies more at risk?

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A report out this week from a Danish hospital claims that if you're pregnant with an IVF, ICSI or other assisted conception baby, then you're four times as likely to have a stillbirth. It makes alarming reading and my worry is that it will cause unnecessary stress to many IVF and ICSI patients who have already been through enough just to get pregnant in the first place.

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Get off to a good start with this guide offering help and support for breastfeeding.

1-to-1 support for breastfeeding

Midwives, health visitors and trained local volunteers (peer supporters) are there to help you get breastfeeding off to a good start. They can give you lots of information and support when you need it.

You can contact your midwife or health visitor between your usual appointments if you need to speak to someone.

You could also go to your local drop-in baby clinic to see a health visitor face to face.

You should find contact details for your midwife or health visitor in your baby's personal child health record (PCHR), known as their "red book".

Ask them to show you the page when you first get it.

Breastfeeding drop-ins, cafes and centres

Breastfeeding drop-ins, cafes and centres are all great places to make new friends and share the ups and downs of looking after a baby.

There's no need to make an appointment - just go along when you can.

To find out what's available in your area:

talk to your midwife, health visitor or GP

contact the National Breastfeeding Helpline on 0300 100 0212 (9.30am to 9.30pm, daily)

contact your local council on GOV.UK who can put you in touch with a Sure Start Children's Centre or Family Information Service, as these often have lists of local breastfeeding groups and activities

use the NHS services search to find a breastfeeding drop-in near you

Breastfeeding helplines and websites

Helplines

National Breastfeeding Helpline: 0300 100 0212

Association of Breastfeeding Mothers: 0300 330 5453

La Leche League: 0345 120 2918

National Childbirth Trust (NCT): 0300 330 0700

The Breastfeeding Network supporter line in Bengali and Sylheti: 0300 456 2421

Websites

Got a breastfeeding question?

Chat to the Start4Life Breastfeeding Friend chatbot on Amazon Alexa, Facebook Messenger, or Google Home for fast, friendly, trusted NHS advice anytime, day or night.

How your partner can support breastfeeding

Getting support from a partner can be very helpful when you're breastfeeding.

Practical ways partners can help with breastfeeding include:

going to antenatal or breastfeeding sessions - some sessions are organised especially for partners - ask your midwife or at a local Children's Centre for details

giving emotional and practical support - praising and encouraging someone who is breastfeeding can help to build their confidence

arranging paternity leave - talk to your employer about paternity leave early on, so you can plan leave that suits your family's needs

making life easier - for example, bring your partner dinner if the baby wants to feed at the same time, or bring them a cup of tea and a magazine while they're feeding the baby, or perhaps arrange for family or friends to keep your partner company while you're at work

doing your bit around the home - so your partner can focus on caring for the baby and getting breastfeeding off to a good start

providing some stress relief - if you have young children, take the stress away from your partner by keeping them entertained when the baby is feeding

getting involved in your baby's care - bathing your baby, changing nappies and helping at bedtime are great ways to get close to your baby

giving your baby a bottle of breast milk - once your partner feels happy and confident with breastfeeding, they may choose to begin expressing breast milk - you could give your baby a bottle of breast milk

Get Start4Life pregnancy and baby emails

For information and advice you can trust, sign up for weekly Start4Life pregnancy and baby emails.

Community content from HealthUnlocked

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Get off to a good start with this guide offering help and support for breastfeeding. Midwives, health visitors and trained local volunteers (peer supporters) are there to help you get breastfeeding off to a good start. They can give you lots of information and support when you need it.

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How to not need a holiday after the holidays

The holidays can be a stressful time for single parents, Natalie is a volunteer in our Wellbeing Digital Group and recently held an online workshop where she shared her 'go to' tools for managing the...

Read more

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We are Gingerbread, the charity for single parent families. We provide expert advice and practical support for single mums and dads in England and Wales.

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Who we are

In 1981 a small group of parents, who were experiencing problems with their crying and sleepless babies, set up a support group. They discovered how important support is and how reassuring it can be to talk to someone. Today that support group has become Cry-sis, the only UK charity offering help and support to parents with babies who cry excessively or have sleeping problems. From modest beginnings Cry-sis has become a well-respected national charity which:

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Support For Crying And Sleepless Babies | Cry-sis

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Cry-sis, the only UK charity offering help and support to parents with babies who cry excessively or have sleeping problems. Call the helpline now...

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Public policy can have an impact on parenting behaviour and achieve positive outcomes for children, but there is currently a lack of evidence on what works - according to new research by the Social Mobility Commission.

The report says that parenting interventions can be successful - particularly those that focus on parenting styles, the creation of a supportive home learning environment, relationships within the family and parental stress and mental health.

Programmes can give parents a greater understanding of child development, develop parents' confidence in their role and support both parents to become actively involved in a child's upbringing.

The research finds that an authoritative parenting style which combines warmth with firmness in setting boundaries, secure attachment between children and parents and the provision of a supportive home learning environment can improve children's outcomes.

It finds that programmes which offer targeted support for parents, are most effective. But these should be termed 'universal' to reduce stigma for those taking part and increase parental participation. Home visits were found to have moderate to high levels of success. It also concludes that highly trained and skilled practitioners, such as nurses, social workers and teachers, are crucial to the successful delivery of parenting interventions.

However, one of the report's key findings is that there is currently a lack of long-term evidence and studies about what parenting interventions work best. The Social Mobility Commission is calling on the government to commission further research to address gaps in this area.

Figures show that, in the last decade, more than 2.5 million children in England - including over 580,000 children known to be eligible for free school meals, had not reached the government's definition of a good level of development at the age of 5.

By the time students receive their GCSE results, around 32% of the variation in performance can be predicted based on indicators observed at, or before, the age of 5.

The Rt Hon Alan Milburn, chair of the Social Mobility Commission, said:

The early years of a child's life have a lasting impact, but there are stark differences in how ready children are for school. In the last decade, over half a million poorer children were not school ready by the age of 5.

We want the government to set a clear objective that, by 2025, every child is school ready and the child development gap has been closed. This requires every low-income family having access to high-quality childcare.

Parenting programmes also have an important role to play in reducing social inequality. But it is clear that there is currently a lack of evidence in this area. The government should commission further research to address this knowledge gap and develop a robust and consistent tool for the evaluation of parenting interventions.

Dr Barbie Clarke, Managing Director of Family Kids and Youth, which carried out the research, said:

Our research shows that public policy can have a real impact on parenting behaviours and achieve positive outcomes for children. Intervention can develop parental management skills and confidence, build healthy family relationships and enhance children's social, behavioural and cognitive development and wellbeing.

Highly trained and skilled practitioners, such as nurses, social workers and teachers, are crucial to their successful delivery. Programmes also need to be universal, but targeted, to reduce stigma and encourage parents to take part.

The 'Helping parents to parent' report was commissioned by the Social Mobility Commission to bring together evidence on parenting behaviours and the extend to which public policy can support parents. It examined 28 interventions and programmes in the United Kingdom and internationally.

Successful schemes examined in the report include:

Home Instruction for Parents of Preschool Youngsters ( HIPPY) runs in several countries and aims to improve the home literacy environment, as well as to enhance the parent-child relationship, to prepare children for school. Aimed at parents of 3- to 5-year-olds, it combines 30 sessions of home visiting and community-centre-based support over 2 years, with daily activities at home. HIPPY has been tested in 9 countries and studies have shown a positive impact on child adaptation and readiness for school.

Parenting Shops in Belgium aim to provide a one-stop 'shop' for a range of parenting support mechanisms. Designed to increase community cohesion and reduce parenting stress, the intervention includes parenting classes, home visits, lectures and local community initiatives such as counselling. Professional staff and some skilled volunteers offer a range of support, and the 'shops' have been shown to be successful in reducing family tension and difficulties.

The Incredible Years operates in several countries, targeting parents, children and teachers. The aim is to increase parents' confidence, competence and coping strategies, and build good parent-child relationships, while helping parents build supportive networks. Delivered through videos, role play and peer support to assist problem solving, research has shown that the programme significantly improves parenting interaction and promotes children's social and emotional wellbeing.

Key recommendations include:

1. There is a need for highly trained practitioners to implement and deliver parenting interventions.

2. There is a need for more family centres or single-access platforms that provide an umbrella of universal parenting support and services and are easily accessible for all families.

3. Home visiting programmes, or those with a home visiting element, have the potential to deliver more success in improving children's outcomes.

4. There is a lack of long-term evidence on parenting interventions and programmes. The government should commission further research on this issue and there needs to be a robust and consistent tool for evaluation.

Notes for editors

1. The Social Mobility Commission is an advisory, non-departmental public body established under the Life Chances Act 2010 as modified by the Welfare Reform and Work Act 2016. It has a duty to assess progress in improving social mobility in the United Kingdom and to promote social mobility in England. It currently consists of 4 commissioners and is supported by a small secretariat.

2. The commission board currently comprises: * Alan Milburn (chair) * Baroness Gillian Shephard (deputy chair) * Paul Gregg, Professor of Economic and Social Policy, University of Bath * David Johnston, Chief Executive of the Social Mobility Foundation

3. The functions of the commission include: * monitoring progress on improving social mobility * providing published advice to ministers on matters relating to social mobility * undertaking social mobility advocacy

4. For further information, please contact Kirsty Walker at the Social Mobility Commission by: * phoning 020 7227 5371 or 07768 446 167 * emailing kirsty.walker@education.gov.uk

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Public policy can have an impact on parenting behaviour and achieve positive outcomes for children, but there is currently a lack of evidence on what works - according to new research by the Social Mobility Commission.

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Find advice on all aspects of family life from bonding with your new baby, dealing with tantrums, positive discipline, bullying, communicating with teens and divorce and separation. You can also call our confidential helpline on 0808 800 2222 or email us for support at askus@familylives.org.uk.

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Parenting advice and family support - Family Lives

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Find advice on all aspects of family life from bonding with your new baby, dealing with tantrums, positive discipline, bullying, communicating with teens and divorce and separation. You can also call our confidential helpline on 0808 800 2222 or email us for support at askus@familylives.org.uk.

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NHS services for new parents

Registering your baby with a GP

Register your baby with your GP as early as possible in case you need their help.

You can use the pink card you'll be given when you register your baby's birth. Sign the card and take or post it to your GP.

You can contact your GP at any time, whether it's for you or your child.

Some GPs will see small babies at the beginning of surgery hours or without an appointment, but be prepared to wait.

Some will give advice over the phone. Most GPs have regular child health clinics.

If you want the GP to see your baby before you have registered the birth, you can go to the surgery and fill in a registration form there.

If you move, register with a new doctor close to you as soon as possible.

If your baby isn't yet registered with a GP but needs to see one, you can receive emergency treatment from any GP surgery.
Find out how to change your GP Find a GP in your area
How your health visitor can help

A health visitor will usually visit you at home for the first time around 10 days after your baby is born. Until then you'll be under the care of your local midwives.

A health visitor is a qualified nurse or midwife who has had extra training. They're there to help you, your family and your new baby stay healthy.

Your health visitor can visit you at home, or you can see them at your child health clinic, GP surgery or health centre, depending on where they're based. They'll make sure you have their phone number.

If you're bringing up a child on your own or struggling for any reason, your health visitor can offer you extra support.

Talk to your health visitor if you feel anxious, depressed or worried. They can give you advice and suggest where to find help.

They may also be able to put you in touch with groups where you can meet other mothers.

Child health clinics

Child health clinics are run by health visitors and GPs. They offer regular baby health and development reviews and vaccinations.

You can also talk about any problems to do with your child, but if your child is ill and likely to need treatment, it's best to see your GP.

Some child health clinics also run mother and baby, parent and toddler, breastfeeding, and peer support groups.

Local authority services

Sure Start Children's Centres

Children's centres are linked to maternity services. They provide family health and support services, early learning, and full-day or temporary care for children from birth to 5 years.

They also provide advice and information for parents on a range of issues, from parenting to training and employment opportunities. Some have special services for young parents.
Find your local Sure Start Children's Centre
Family Information Service

Your local Family Information Service (FIS) aims to help you support your children by providing a range of information specifically for parents.

Each FIS has close links with children's centres, Jobcentre Plus, schools, careers advisers, youth clubs and libraries.

They offer information about local childcare services and availability, and can help you if you need childcare for a child with a disability or special needs.
Find your local Family Information Service

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Register your baby with your GP as early as possible in case you need their help. You can use the pink card you'll be given when you register your baby's birth. Sign the card and take or post it to your GP. You can contact your GP at any time, whether it's for you or your child.

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East Herts Twins Club meets during term time on Tuesday mornings from 10:00-11:45am. There is plenty of parking on site. Occasionally we open during school holidays - please check our Facebook page for details. Cost is £3 per family for each session, which includes hot drinks and biscuits (plus covers hall hire/insurance, we are non profit making). The sessions are stay and play with refreshments and lots of friendly faces for any support or advice needed. Please also ask on our Facebook page for any twins or more advice! Or email us for further information.

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East Herts Twins Club meets during term time on Tuesday mornings from 10:00-11:45am. There is plenty of parking on site. Occasionally we open during school holidays - please check our Facebook page for details. Cost is £3 per family for each session, which includes hot drinks and biscuits (plus covers hall hire/insurance, we are non profit making).

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We offer confidential bereavement support to anyone affected by the sudden and unexpected death of a baby or young child.

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Sands - Saving babies' lives. Supporting bereaved families.

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Sands | Saving babies' lives. Supporting bereaved families.

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Sands works to support anyone affected by the death of a baby; improve the care bereaved parents receive; and create a world where fewer babies die.