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'Microbirth' told us of the importance to our immune systems of seeding the microbiome. Independent midwife Sally Randle describes how the theory is making its way into practice for some of her clients.

Last year I attended the screening of One World Birth's film Microbirth organised by a local Bristol AIMS member. A couple of weeks before I had watched a fascinating BBC Horizon programme about allergies in young children, in which it was discovered that a 5 year old boy with severe, sometimes life threatening allergies, had none of the many bacteria in his body that he was supposed to have as a human being but plenty of those he shouldn't, i.e. hospital acquired bacteria. He had been in special care after birth and was not breast fed.

This was the first time I heard about the microbiome and its importance to our immune systems and basic structure of our human bodies. Fortune Magazine has declared 2015 'The Year of the Microbiome', and there is significant research going on to fully understand its complex relationship to health and disease, notably the multimillion-dollar five-year Human Microbiome Project. The Microbirth documentary told us that babies pick up many of these vital bacteria on their passage through the birth canal, with skin to skin contact with their mother and when breastfeeding, as well as in utero. The study mentioned in the film was not completed (although preliminary evidence was showing good results) but I decided that I would bring this issue up with my clients when we have our initial birth plan discussion at around 30 weeks. They could then explore the issue further for themselves and incorporate the suggested method of seeding the biome into their caesarian section birth plan, if they felt convinced by the emerging evidence. I suggest to all my clients that they consider caesarian section as a possible outcome at this stage (although with IM care it is considerably less likely than the 20 - 25% of most hospitals) in terms of writing down how they would like it to go, then put the whole subject away literally and emotionally.

I fully expected to encounter some puzzled looks and even flat out refusal to consider it, from health professional colleagues, if 'seeding the biome' was brought up, but as an IM I am used to shouldering these reactions on behalf of my clients. I remembered we had already sometimes experienced these attitudes in the past, when we asked surgeons to avoid premature cord clamping at caesarian section and leave the cord to pulsate as long as possible. I reminded myself that now a few years on this practice is generally accepted as beneficial to the baby and is widely practised.

So cue my most recent client, Ursula. She experienced a powerful VBAC labour, which got so much further this time than it did last time. Her body went into labour by itself and worked so hard along with her baby to get her born. Ursula decided, after many many hours, that another caesarian section was the right action to take. She hadn't written a birth plan, but once she had made the decision for another caesarian, she told the surgeon her wishes as far as the operation went: which were for immediate skin to skin contact in theatre, early breastfeeding, avoiding premature cord clamping and for her baby's micro biome to be seeded immediately after birth. She and the obstetrician turned to me for an explanation of how this is done.

"I fully expected to encounter some puzzled looks and even flat out refusal to consider it, from health professional colleagues, if 'seeding the biome' was brought up but as an IM, I am used to shouldering these reactions on behalf of my clients"

I explained the method suggested in the film: that you take a large surgical swab and fold it fan like (for largest surface area) and insert in the mother's vagina at the start of the operation. Take it out when baby is born and wipe it downwards over the baby from the head, including the face and very importantly inside the mouth. The surgeon listened attentively and then turned to the hospital midwife who had been caring for my client and who would accompany her into theatre (I am not allowed to do this at this hospital) and asked how they might best facilitate this for Ursula and Barney. They agreed that since they would have "vaginal access" when the midwife inserted the urinary catheter it would be at this point they would put the swab in. They also discussed the immediate skin to skin and leaving cord to pulsate with my client and agreed that these things would happen as long as the midwife assessed the baby's condition as good when she was born. I also suggested that Ursula put a towel down her front next to her skin, if she could, so the first towel baby had (after sterile one used to receive baby in sterile field of operation) would be one covered in her skin micro bacteria.

By the way hospitals are rightly very strict about swabs in operating theatres and will want it back as soon as possible for their vital swab count, but this should not be a reason to refuse to give you one.

An hour and a half later they returned from theatre with their gorgeous baby girl in arms. Everything had gone well and all their wishes had been met. Someone in theatre had decided that Barney should be the one to seed his baby's biome (this may have been defensive I guess, but was an inspired idea whatever the motive) because Barney was so proud and pleased to have been able to do this for his child; to overcome the limitations of caesarian section in this area and potentially give his daughter's immune system this huge boost. What a brilliant role for the birth partner to play. I will never forget the look of joy and pride on his face as he held his daughter in his arms and told me how he had done this.

Personally I would like to thank the obstetrician and the midwife who cared so wonderfully for Ursula and Barney and their baby. My IM colleague's will know that it is not always such an easy and straightforward path to help our clients gain the support of other health care professionals for their intentions and plans. This lovely obstetrician and midwife listened to my clients, worked out the best way of helping them and respected their wishes to the letter.

"What a brilliant role for the birth partner to play. I will never forget the look of joy and pride on his face as he held his daughter in his arms and told me how he had done this"

For more information about the body's bacteria and the importance of contact with the birth canal for the baby click here and here.
Sally Randle offers individualised maternity care from one midwife for pregnancy, birth and afterwards for women living in Bristol, Bath and the surrounding area.
Stay in touch! 'like' the IMUK Facebook pag e for more posts like this.

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IMUK | Sowing the seeds of future health

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'Microbirth' told us of the importance to our immune systems of seeding the microbiome. Independent midwife Sally Randle describes how the theory is making its way into practice for some of her clients. Last year I attended the screening of One World Birth's film Microbirth organised by a local Bristol AIMS member.

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Baby-led attachment is letting baby follow their instincts to find the breast and attach. It can help you get started and overcome breastfeeding challenges.

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What's in Breastmilk/Formula?

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induction for macrosomia (printable) (1)

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Trying different parenting styles and approaches can help you to make long-term decisions about your baby's care. Read about different parenting skills and models here.

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'Motherhood changes you forever' - the cliché your own mother forewarned you. And she was right. Motherhood, and specifically breastfeeding - the most central physiological act of mothering during infancy, changes you because it literally alters your brain - structurally, functionally, and in many ways, irreversibly. I am about to explain how the act of nursing sets apart mothers who breastfeed from those who don't - on a neurological scale.

Breastfeeding mothers and their babies are attuned to each other on a deep biological level. In fact, a breastfeeding mother and her baby are sometimes referred to as a 'dyad' - two individuals so closely linked they are considered one unit. Her body nourishes him; his feeding determines her milk production. Scientists call this 'limbic regulation'. It's a remarkable natural phenomenon whereby the mother is neurologically and chemically in sync with her baby, and her baby to her. Michael Merzenich, the San Francisco University brain plasticity expert, has described breastfeeding as a kind of temporary breakdown of identity for both mother and child that powerfully affects both their brains. "At that point, the baby and the mother are unified" (Merzenich 1994). Glassy eyed, who, me?

New Pathways

When you breastfeed, you are relating to this little person in a way you have never related to anyone else in your life. The process of a baby suckling at the breast actually forges new neurochemical pathways in the mother's brain that create and reinforce maternal behaviour. This process is aided by chemical imprinting and huge increases in oxytocin. These changes result in a motivated, highly attentive, and aggressively protective brain that compels the breastfeeding mother to alter her responses and priorities in life (Hahn-Holbrook 2011). This hormonal cascade makes mom want to respond to her baby and helps her to interpret his needs effectively (Rapley and Murkett 2012).

When a mother nurses, not only do her blood oxytocin levels increase, but her body makes more receptors, permanently increasing her feelings of love - and her ability to feel loved. Mom's sensitivity to oxytocin's power is one of the most fundamental ways she changes as a new mother. In humans, we have oxytocin receptors snuggled within our breast tissue. As Sweden's Karolinska Institute, Kerstin Uvnas-Mobery, the global authority on oxytocin, found in a series of experiments, breastfeeding women tend to be less reactive to stress hormones, less physically tense, less suspicious, and less bored. They are also calmer and more sociable when tested for these traits than mothers of comparable ages who are not breastfeeding (Uvnäs-Moberg & Petersson 2005).

But the accolades don't stop there! In another study, this time conducted by Margaret Altemus, a psychology professor at Cornell University, 10 lactating and 10 non-lactating women were stressed by being forced to engage in one of my favourite past times - pounding a treadmill for no particular reason. The research team found the lactating women released only HALF the amount of stress hormones, compared to those not nursing (Altemus 2010). Other studies back this up. It appears that oxytocin not only lowers blood pressure but also inhibits the release of the stress hormone glucocorticoid. Glucocorticoids are one reason why prolonged stress can damage the hippocampus. Meanwhile, prolactin, dubbed 'the parenting hormone', dampens fear and anxiety by inhibiting the amygdala (the part of the brain responsible for fear responses) (Kirsch 2005). Zen! The two hormones are elevated each time baby suckles at the breast reaching blood levels of eight times the norm (Ellison 2006). In other words: breastfeeding moms' antistress systems are frequently activated and they are buffered. Oxytocin is Mother Nature's weapon against stress, an innate mechanism that mammal mothers enjoy so that stress doesn't interfere - and least not too much - with mental function. As Stanford biologist Robert Sapolsky, an international expert in stress (would you want his job?) has remarked: "Somehow mammals have worked this out, because cognition is a good thing to have when you have small dependents" (Sapolsky 2014).

Breastfeeding mothers respond to stress less with the banal 'fight-or-flight' model (commonly seen in men) and more with an alternative one that has been named 'tend-and-befriend' - with friendliness rather than anger. This 'female model of the stress response' is again, thanks to lactation's triggering of oxytocin (Taylor 2000; McCarthy 1995). Throughout most of human history, women have had to watch out not just for themselves but for the sprogs they most likely had in tow. Their bodies knew they had little people to care for purely because of the signals produced through sustained lactation. A consequence of this biology is that each gender has evolved differently in the matter of psychological responses to stress. Formula feeding mothers respond to stress like men, in a more 'fight or flight' manner, due to their low exposure to oxytocin relative to lactating mothers. This in part explains why breastfeeding mothers are significantly less likely to abuse their babies (Strathearn 2009; On this touchy topic, see also: 'Why the Way You Feed Your Baby is MY Business').

Dr Kerstin Uvnas-Moberg, a world authority on oxytocin, has studied the changes between these two defence mechanisms, where she refers to the 'tend and befriend' approach as 'calm and connection'. In her book 'The Oxytocin Factor' she compiled two striking lists:

For breastfeeding moms, it's an upward spiral. The longer and more often their baby suckles, the more it triggers the prolactin-oxytocin response in the mother's brain, forging more connections. Pretty soon, the mother forges enough receptors that she can feel her breasts tingling and leaking at the sight, sound, or merely passing thought of nursing her baby. As one Warwick University study discovered:

"Breastfeeding causes a massive increase in communication between the neurons, co-ordinating a 'swarm' of oxytocin factories producing intense bursts of the hormone". To illustrate, take a gander at the virtuous circle depicted in the diagram below:

When a baby grasps its mother's breast with tiny hands and sucks on her areola, it triggers explosive bursts of oxytocin and prolactin, prompting bursts of dopamine, in the mother's brain. Prolactin is detected by a sensitive area on each milk-making cell and has the effect of priming them, or switching them on. Breast milk then begins to flow. These 'receptors' are much, MUCH stronger in lactating mammals than non-lactating mammals (Tzanou et al 2007). When these receptors are stimulated they make the mother want to protect her baby and hold him close.

These hormonal interactions create the notorious 'breastfeeding bond', switching off negative emotions and switching on pleasure circuits that produce feelings of exhilaration and attachment (Domes et al 2007; Hurlemann et al 2010). The hormonal exchange works as follows: The nursing response of the oxytoxin circuits is reinforced by the feeling of pleasure created by bursts of dopamine - the pleasure and reward chemical. Dopamine is jacked up in the mother's brain by estrogen and oxytocin. The mother's blood pressure drops, she feels peaceful and relaxed, and she basks in waves of oxytocin-inspired loving feelings for her baby. This neurological mechanism explains one of the ways that breastfeeding reduces the risk of a mom developing postpartum depression (Figueiredo et al 2013; Figueiredo et al b 2013; Hahn-Holbrook et al 2013). Think of it like walking through a forest the same way again and again, each time making a clearer trail - this is what's happening in mom's brain. Circuits that activate as she breastfeeds, become stronger and respond more readily.

More Powerful Than Cocaine

Let's explore this feel-good mechanism in even more detail. In one study, mother rats were given the opportunity to press a bar and get a squirt of cocaine or press a bar and get a rat pup to suck their nipples. Which do you think they preferred? Those oxytocin squirts in the brain outscored a snort of cocaine every time.

To give you another example of oxytocin's potency, male prairie voles given a shot of the stuff are converted from roving-eyed bachelors into nurturing husbands and fathers (Ellison 2006).

Enhanced Empathy

In one Yale University study, a team of researchers examined new mothers - half who were breastfeeding, and half who were formula feeding. Two to four weeks after giving birth, the mothers had their brains scanned using a swanky 'functional magnetic resonance' (fMRI) machine while they listened to recordings of their babies' cries. Why their cries? I can think of better stuff to put on my ipod. Why not their cute baby gurgles? Or their babbles? Well, the focus on crying was strategic: as I have discussed elsewhere, responding promptly and lovingly to a baby's cry is an important part of helping that baby develop trust, a feeling of safety, of worthiness, and of mental well-being. The results of this Yale experiment revealed that the brains of the breastfeeding mothers showed a significantly stronger response to the sound of their babies' cries than did the brains of the formula feeding mothers. Greater activity was revealed in several brain regions, including the superior frontal gyrus, striatum and amygdala. The researchers hypothesised that high activity in these regions contributes to breastfeeding mothers' ability to understand how their babies are feeling and respond in an appropriate way (Kim et al 2011). In other words: breastfeeding mothers are more attentive than their formula feeding peers. Mammaries: 1. Man-Made Powder: 0.

The amazing hormonal cascade induced by lactation doesn't end there. Lactation also facilitates learning and memory specifically for social information. Breastfeeding mothers show improved memory for human faces, in particular happy faces (Rimmele et al 2009; Guastella 2008). They also show improved recognition for positive social cues (Unkelbach 2008; Marsh 2010) and improved recognition of fear in others (Shofty 2010).

To examine how important this process is, let's take a look at rats again. Female rats inhibited from producing oxytocin after giving birth do not exhibit typical maternal behaviour (Van-Leengoed 1987). They show a marked delay, and in some instances avoidance, of pup carrying, pup manipulation, nest building, autogrooming, and time spent on the nest with the pups. At the end of 1 hour, two out of the six mothers had not yet picked up a single infant. Consider that human mothers who formula feed are literally inhibiting their oxytocin production, lack of lactation is literally stunting their maternal brain circuits. Contrast this with mothers who breastfeed, they have been found to exhibit more behaviors that create a close relationship to their baby, such as singing a special song to them, bathing and feeding them in a special way, or thinking about them more (Odent 2011). Quite simply, the more oxytocin you have, the more loving and attentive you are to your baby. The reserve is equally true.

The breastfeeding mother has a brain that is literally marinating in oxytocin and dopamine making her feel loved, deeply bonded, and physically and emotionally satisfied. Just check out the smorgasboard of other psychological and physiological changes that oxytocin brings about in breastfeeding moms:

Enhanced Smarts

In the same way that lactation gives breastfeeding mothers the edge over formula feeding mothers on the attentiveness front, it also makes them smarter than their bottle wielding peers. By 'smart' I'm not talking about Hawkingesc quantum physics - nope - the smarts of a breastfeeding mother mean much more than that. I'm talking about the kinds of smarts that translate into enhanced perception, efficiency, resiliency, motivation and social skills. This is a topic I explore in depth in my book when I speak of breastfeeding mothers as 'positive deviants'. Breastfeeding is nature's academic plan for mothers. Harvard psychiatrist Dr John Ratey explains:

"When a mother gives birth, you want her to be really smart, as smart as she can be. You want her to know about the territory around her and remember things about her kids, and be in a prime state to function" (Ratey 2003).

When Dr Ratey examined the brains of mothers in late pregnancy, he found that their normal rate of cell replacement had slowed down and brain size had shrank - an event which may explain the oh-so-dopey 'mommy brain' fog of the third trimester. However, once mom has given birth and breastfeeding begins, cell replacement resumes and increases. Compared to those not breastfeeding, Dr Ratey found that lactating moms had more glial cells, which support the neurons by importing energy and exporting waste products.

Let me give you an example of these cells in action: breastfeeding mothers are more sensitive to the sounds of their own babies, and more skilled in interpreting what they mean. A breastfeeding mom's pricked-up ears (as discussed in that crying experiment we spoke of earlier) make her more perceptive and aware - in a word, smarter - about her child. This perceptional ability becomes part of her general feeling of extraordinary attachment to this new being. Strong attachment itself can help make her smarter about the rest of the world, in part by keeping her brain elevated.

Then there's the sensory aspect: a mother's skin as she nurses her baby, is her most direct and loving means of communication, just as her suckling baby talks back with lips and hands, egging her on, before he knows a single word. Katherine Ellison, author of The Mommy Brain has extensively researched this area. She has noted that:

"Studies on animals strongly suggest that breastfeeding re-plots the map of the brain. When my baby son lay on my chest, he had direct impact on my sensory hormunculus. With repeated input from suckling and nestling, my chest, which used to be a purely aesthetic part of my personal repertoire, had acquired a leading role in the nurturing of another human being - and also in the way I was imagining myself, interpreting the world, and learning to behave".

A decade ago, two neuroscientists, Judith Stern at Rutgers University and Michael Merzenich at the University of California, provided stunning evidence of this impact when they showed that in the cortex of a mother rat, the area devoted to the trunk, or chest, had actually doubled in size while that rat was breastfeeding. Both Stern and Merzenich have little doubt that the same kind of thing happens in humans:

"It is probable that human lactation results in substantial representational remodeling in most or all of more than 10 different somatosensory representational areas, as well as in a number of motor and

premotor zones" (Stern and Merzenich 1994).

Another boffin known for his scientific brilliance, anatomist Vincenzo Malacarne, has noted that breastfeeding is an especially powerful cognitive experience because it involves, in his words, "learning under high stakes conditions, which is just the sort of learning that drives changes in the brain". In his work he discovered how lactation increases synapses in the part of the brain's cortex that deals with attention and complex tasks. This however, he did not find surprising: "In breastfeeding, you are relating to another person like you never related to anyone before. In a sense, you are one person, and it's pretty educational to have another human being extending into the makeup of your own self" (Ellison 2006). Indeed, breastfeeding forces moms to use certain talents up-close, constantly and repetitively. And, unlike the mental challenges of studying or working at a job, it's much harder to check out for any length of time when you're on the spot for nourishing. Add to this the fact that breastfeeding reduces stress via oxytocin, and opportunities for learning are improved even further. Have you ever tried to learn something new when you're under stress? Breastfeeding strikes the perfect balance between keeping mom alert and yet also relaxed - an equalibrium which improves her overall comprehension skills.

Enhanced Efficiency

Does breastfeeding make a woman a more efficient mother? Formula apologetics would unsurprisingly argue - no. However suppose we did an experiment. Perhaps this experiment could involve depriving families of food and then watching to see which mothers were most efficient at obtaining it. Who would come up trumps, breastfeeders or formula feeders? This would, of course, be highly unethical, and so the hypothesis can never be tested on humans, but other mammals - bring it on. And that's exactly what psychologist Dr Craig Kinsley did with our friends, the rats. He looked at the behaviour of age-matched rat moms, comparing those who were lactating and those who were not. The rats were temporarily deprived of food and then given crickets. In order to feed, the rats had to capture and kill the crickets whilst Kinsley's team observed.

In the animal world, a heightened ability to capture prey means a decreased amount of time the mother spends away from vulnerable offspring and this decreased window of vulnerability means a lower infant mortality rate. The results of Kinsley's study showed that lactation gives mothers the edge, with the non-lactating rats taking around 290 seconds to catch the crickets, whilst the lactating group only took about 70 seconds. Speaking of his findings, Kinsley commented: "The lactating brain expresses a great deal of plasticity and creativity in service to, and in support of, reproduction. In other words, mothers are not born, they are made through breastfeeding" (Kinsley and Lambert 2006). And what's more, the breastfeeding rats' gains in learning and memory were lasting up to twenty-four months, a full eighteen months past their last litter, and the equivalent of about 80 years of age for a human! 80 years, people!

Another research team, this time from Okayama University in Japan, found more evidence to support the existence of permanent change. They discovered something called 'long-lasting, long-term potentiation', known as L-LTP, in the hippocampi part of the brain of lactating mammals. L-LTP is a psychological marker of long-term memory foundation, involving an actual increase in the efficiency of synapses - i.e. the structure that permits a neuron to pass a signal to another cell (Tomizawa et al 2003). Essentially: the changes to a mother's brain do not subside once mom stops breastfeeding. Scientists have good evidence to believe that permanent changes occur. They base this partly on research showing that humans and other mammals respond more readily, and emotionally, to their second baby than to their first. This is much more than a matter of knowing what to expect: the differences appear to become hard-wired, even influencing mothers' milk flow, which is generally freer second time around (Ellison 2006).

In short, breastfeeding mothers are more present, focused, and organized - changes which last for the entirety of a woman's mothering AND grandmothering journey. Just as nursing rat mothers build a nest, protect their young from danger, and keep them clean, so nursing human mothers perform in comparable ways - and keep on performing.

Adoptive mothers and formulas feeders can also lap up these benefits. How? Well, it's not easy. When virgin rats are injected with breastfeeding hormones (doing this to humans would be deemed 'unethical' so here we have the rats again), they go from their usual behaviour of rejecting rat pups, to nurturing them (Moberg 2011). Adoptive human mothers can induce lactation to produce the same effect. Formula feeders can relactate.

Wow. You've just sat through a neuroscience lecture. That's a lot of learning, and being a badass breastfeeder, you probably soaked it all up. Let's sum up this post: Breastfeeding is so much more than nutrition - it changes the architecture of the brain. The way neurons in a woman's brain are restructured in response to lactation enables her to respond to her baby with a richer and more enhanced behavioural repertoire. In the blood, lactation hormones govern milk ejection, while in the brain they affect behaviour. And these changes are the most profound and permanent of a woman's life. Mother Nature knows her stuff.

Now, of course, since breastfeeding is the biological norm for humans, an accurate conclusion from the science is not "Breastfeeding makes mothers more empathic, more intelligent and more efficient" but rather: "Formula feeding makes mothers less empathic, less intelligent, and less efficient". Oh dear, sirens are going off at Formula Feeder HQ...

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How Breastfeeding Changes Your Brain - The Alpha Parent

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'Motherhood changes you forever' - the cliché your own mother forewarned you. And she was right. Motherhood, and specifically breastfeeding - the most central physiological act of mothering during infancy, changes you because it literally alters your brain - structurally, functionally, and in many ways, irreversibly.

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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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If this is your first baby, you will be adjusting to your new role as father and family man. If you already have a family, the whole family is adjusting to the new dynamic. Because every child is different, each child is a unique and new adventure. Give yourself lots of unstructured time to get to know your baby and adjust to your new lifestyle.

Babies remain otherworldly for the first few weeks after birth. They are in the world, but are not yet quite here. Because your baby has just emerged from the womb, you are adjusting to the new order after birth, and so is your baby. (From here on, the masculine pronoun is used to refer to your baby since no appropriate pronoun refers to both sexes.) Before birth, your baby was held in the fetal position and wrapped securely by the womb, where it was dark and warm. Other than the beat of your partner's heart and breath, sounds were muffled.

A newborn baby has never known hunger, cold, sight, or light. Your baby was immersed in water in the womb, so he is also adjusting to the effects of gravity and air. During your baby's last few months in the womb, his movement was tightly restricted. Swaddling him is familiar and comforting, since he is used to being in a tight, warm space. Too much freedom of movement can startle or distress babies. Using a receiving blanket to swaddle your baby before you lay him down helps him go to sleep more quickly and sleep longer.

A newborn cannot support his head. When you pick up or hold your baby, support his head. But babies are resilient. You don't have to be overly cautious. Relax and enjoy your infant. William, an experienced father, said it like this: The first baby is kind of like glass. But the second one is kind of like rubber.

During this otherworldly phase, you will be getting to know your baby, and he will be getting to know you. When you hold your newborn, he does not yet know where his body ends and yours begins. Your body and his body are blended into one experience for him.

It is a great gift to your baby if you eliminate as many distractions as possible. But it is a greater gift to you if you eliminate distractions and focus on the job at hand-getting to know your baby and adjusting to the new order.

Most women choose to breastfeed (nurse) their baby, but some choose to bottle-feed. If you have an opinion on how your baby should be fed, express yourself, but do so in a way that gives your partner the freedom to find her own path. Feeding is one of the primary activities in caring for the baby. Whether your partner breastfeeds or bottle-feeds, she needs your committed support. When your partner feeds the baby, make sure she is comfortable. Wedge pillows to support her arms and head; offer fluids and nutritious snacks.

Some women have demanding jobs that prevent them from breastfeeding. Others cannot nurse because of a chronic health problem, and some need medication that is harmful to the baby and therefore nursing is contraindicated. Some women want to nurse, but have so many difficulties with it that they cannot establish the practice. Others simply do not want to nurse. They prefer to have their partners and other people involved with the feeding, and choose not to tackle a job that no one else but the mother can do.

Nursing has become such a charged issue that women who do not or cannot nurse may feel guilty or judged. Every woman has to navigate the way she has chosen. No woman should be judged for doing it the way she has to do it. Since the beginning of humankind, some situations have required that babies get milk from other sources than their mothers. If a baby is loved and nourished, that's all that matters. Everything else pales by comparison.

Nursing is a tremendous undertaking of time, dedication, and energy- more than either of you can possibly imagine. Your partner can spend eight hours (or more) in a twenty-four-hour day nursing. Nursing is a full-time job. It is also a practice and an art. While breastfeeding is natural, it does not necessarily follow that your partner will intuitively know how to do it. She needs instruction and support, as well as lots of fluids, good nutrition, and rest to successfully nurse.

Even though it may appear that a mother is just sitting and nursing, a nursing mother burns more calories and uses more energy than a man who works in construction. Give her this special time, to the best of your ability, without resentment or criticism. Your baby will flourish because of it. And the favor will be returned to you and your family a hundredfold.

It takes your partner and baby several weeks to become established in the art of nursing. Your partner may have times when she doubts her ability or desire to nurse. Your rock-solid confidence in her ability can support her through those times and make the difference between a successful, long-term nursing experience or a shortened, frustrated one.

Nursing is beneficial to mother and baby, and it helps the mother recover from birth. In order for your partner to have a letdown and release the milk from her breasts, her body must release the hormone oxytocin. Oxytocin helps the uterus contract back to its normal size and reduces postpartum bleeding, as well as engendering feelings of love in your partner. However, oxytocin cannot be released if your partner is anxious. Both mother and baby become fretful if your partner is having difficulty with her letdown.

If your partner is having trouble establishing nursing (and most first-time moms do), your calm, stable attendance can make the critical difference. Encourage her to seek help from a lactation specialist, La Leche League, a postpartum doula, or another experienced nursing woman. It takes about four weeks for a woman and her baby to establish the art of nursing; after that it becomes easier for both of them.

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If this is your first baby, you will be adjusting to your new role as father and family man. If you already have a family, the whole family is adjusting to the new dynamic. Because every child is different, each child is a unique and new adventure.

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This article covers:
Background of vitamin K after birth
Are some babies at higher risk of HDN?
What are the effects of giving vitamin K by injection?
What are the effects of giving vitamin K orally?
Why were breastfed babies thought to be at increased risk?
Should women take vitamin K?
Possible vitamin K deficiency symptoms to watch out for

In the UK, parents of new babies are routinely asked if their baby is to have supplementary vitamin K by injection or oral supplement, which is needed to make blood clot and prevent excessive internal bleeding.

"Compared with adults, newborn babies are born with low levels of vitamin K but the amount is normally sufficient to prevent problems. Some babies are at risk, however, because they don't have sufficient vitamin K, and they have an increased risk of Haemorrhagic Disease of the Newborn (HDN), also known as Vitamin K Deficiency Bleeding (VKDB)".

While some babies are at a higher risk than others (see below), some babies who are at risk of bleeding don't show any risk factors and, for this reason, the Department of Health recommends all babies are given vitamin K soon after birth, usually by injection. However, it is your choice as a parent to decline, if you wish; you can also opt for vitamin K to be given by mouth instead.

Background of vitamin K after birth

HDN is a rare but very serious disease. Half of all babies who have HDN have a haemorrhage into their brain (intracranial bleeding). This often causes brain damage, and the baby may die. In the 1950s and 1960s, it became standard practice for all babies to have an injection of vitamin K into a muscle.

Later, in the 1980s, some health professionals and parents wondered if it was necessary to give vitamin K injections to every newborn baby. Instead, single doses by mouth became popular, and some babies, if they were not deemed to be at higher risk, were not given the supplement at all.

A UK study published in 1991 confirmed that HDN was rare. The babies who had HDN were more likely to have liver disease or be breastfed. Then, in 1990 and 1992, studies were published that suggested a possible link between injected vitamin K and childhood cancers including leukaemia. This meant more babies were given vitamin K by mouth. The number of babies with HDN went up slightly as a result, perhaps because oral vitamin K is slightly less effective than when it is given by injection.

Since then, further studies have failed to find any link between injected vitamin K and childhood cancers of any type and, in 1997 an expert body for the UK Department of Health concluded that this was no longer a concern.

Are some babies at higher-risk of HDN?

Babies at increased risk of HDN include:

Babies born after less than 37 weeks of pregnancy.

Babies whose birth involved the use of forceps, ventouse or caesarean, where bruising occurs.

Babies who had trouble breathing and did not get enough oxygen when they were born.

Babies whose mum are taking anti-convulsants, anti-coagulants, or drugs to treat tuberculosis.

Babies who have liver disease that may show as prolonged jaundice or symptoms, such as pale stools or dark urine.

This means that about a third of babies are at increased risk. Some studies suggest that many of the babies who develop bleeding have unseen problems with their liver. It is hard to spot these babies before they bleed, so vitamin K can be preventive.

What are the effects of giving vitamin K by injection?

Giving vitamin K by injection probably keeps levels higher for longer, compared with vitamin K by mouth, as it remains stored in the muscle where it was injected.

Problems from the injection are very uncommon but may happen, as with any injection. Babies can feel pain and, on rare occasions, may have an infection at the place where the injection goes in, or bleeding and bruising in the muscle.

Mistakes are very occasionally made with the injection, and the wrong dose or drug may be given.

What are the effects of giving vitamin K orally?

Oral vitamin K is given in three separate doses, over the first month of life. Studies have shown that sometimes, a dose is omitted, probably because it's forgotten about, and this means full protection is not given.

Why were breastfed babies thought to be at increased risk?

According to studies, HDN was more common among breastfed babies.

We know vitamin K levels are higher in colostrum (the first milk you produce) than in mature milk.

In the past, babies were not breastfed till some time after birth, and strict feeding routines were usual; this probably meant that babies got less vitamin K than nature intended. Nowadays, babies are usually breastfeed soon after birth, and they feed frequently for as long and as often as they want. This means they get more colostrum than they used to, reducing the risk of HDN.

Formula milk has vitamin K added to it.

Should women take vitamin K?

Giving vitamin K to mums before and after they have their babies has been tried in small-scale studies. Vitamin K does go across the placenta and into breastmilk, but it does not seem to be sufficient to prevent HDN.

Possible vitamin K deficiency symptoms to watch out for

If your newborn bleeds, for example, if you find blood oozing from the cord stump, or if bleeding continues for some time after the 'heel prick' blood test, or if your baby has a nose bleed or unexplained bruising, then talk to your doctor or midwife. They need to be checked in case this bleeding is a sign of HDN. If your baby has jaundice lasting longer than two to three weeks or is producing pale poos and dark urine, you should raise it with your doctor or midwife, because this may be a sign of liver problems, which increases the risk of abnormal bleeding.

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.

You might find attending one of NCT's antenatal courses or Early Days groups helpful.

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

You can read Vitamin K in Neonates: facts and myths by Giuseppe Lippi and Massimo Franchini (Blood Transfusion 2011) for more information.

NHS Choices has some useful information in their Your baby after the birth section

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Vitamin K: Injection or oral dose for newborns

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This article covers: Background of vitamin K after birth Are some babies at higher risk of HDN? What are the effects of giving vitamin K by injection? What are the effects of giving vitamin K orally? Why were breastfed babies thought to be at increased risk? Should women take vitamin K?

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All parents are offered a thorough physical examination for their baby within 72 hours of giving birth.
The examination includes screening tests to find out if your baby has any problems with their eyes, heart, hips and, in boys, testicles (testes).

What is the newborn physical examination?

The newborn physical examination is usually carried out in hospital before you go home.

Sometimes it's done at a hospital or community clinic, GP surgery, children's centre or at home. Ideally, both parents should be there when the examination is done.

The healthcare professional doing the examination should explain what it involves. This could be a doctor, midwife, nurse or health visitor who's been trained to do the examination.

Some parts of the examination may be a bit uncomfortable for your baby, but it will not cause them any pain.

The aim is to spot any problems early so treatment can be started as soon as possible. Usually, nothing of concern is found.

If the healthcare professional doing the examination does find a possible problem, they may refer your baby for more tests.

You'll be offered another physical examination for your baby at 6 to 8 weeks, as some of the conditions it screens for can take a while to develop.

This 2nd examination is usually done at your GP surgery.

How is the newborn physical examination done?

The healthcare professional will give your baby a thorough physical examination.

They'll also ask you questions about how your baby is feeding, how alert they are, and about their general wellbeing.

Your baby will need to be undressed for part of the examination.

During the examination, the healthcare professional will also:

look into your baby's eyes with a special torch to check how their eyes look and move

listen to your baby's heart to check their heart sounds

examine their hips to check the joints

examine baby boys to see if their testicles have descended into the scrotum

What does the newborn physical examination check for?

The examination includes an overall physical check, plus 4 different screening tests.

Eyes

The health professional will check the appearance and movement of your baby's eyes.

They're looking for cataracts, which is a clouding of the transparent lens inside the eye, and other conditions.

About 2 or 3 in 10,000 babies are born with cataracts in one or both eyes that need treatment.

But the examination cannot tell you how well your baby can see.
Find out more about childhood cataracts
Heart

The healthcare professional will check your baby's heart. This is done by observing your baby, feeling your baby's pulses, and listening to their heart with a stethoscope.

Sometimes heart murmurs are picked up. A heart murmur is where the heartbeat has an extra or unusual sound caused by a disturbed blood flow through the heart.

Heart murmurs are common in babies. The heart is normal in almost all cases where a murmur is heard.

But about 8 in 1,000 babies have congenital heart disease that needs treatment.
Find out more about congenital heart disease
Hips

Some newborns have hip joints that are not formed properly. This is known as developmental dysplasia of the hip (DDH).

Left untreated, DDH can cause a limp or joint problems.

About 1 or 2 in 1,000 babies have hip problems that need to be treated.
Find out more about developmental dysplasia of the hip
Testicles

Baby boys are checked to make sure their testicles are in the right place.

During pregnancy, the testicles form inside the baby's body. They may not drop down into the scrotum until a few months after birth.

Around 2 to 6 in 100 baby boys have testicles that descend partially or not at all.

This needs to be treated to prevent possible problems later in life, such as reduced fertility.
Find out more about undescended testicles

Does my baby have to have the examination?

The aim of the examination is to identify any of the problems early so treatment can be started as soon as possible.

It's strongly recommended for your baby, but not compulsory.

You can decide to have your baby examined and screened for any or all of the conditions.

If you have any concerns, you should talk to your midwife or the healthcare professional offering the examination.

When will we get the results?

The healthcare professional who does the examination will give you the results straight away.

If your baby needs to be referred for more tests, they'll discuss this with you there and then, too.

The results will be recorded in your baby's personal child health record (red book).

You'll need to keep this safe and have it to hand whenever your baby sees a healthcare professional.

If you have any concerns, you can discuss them with your midwife or the healthcare professional who does the examination.
Download a leaflet about screening tests for you and your baby from GOV.UK

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All new parents are offered a newborn physical examination for their baby. Your baby's eyes, heart, hips and, in boys, testicles will be checked.

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Ethnographers have long noted a striking phenomenon: Inuit and African babies generally tend to be much calmer than western babies. In fact, they cry very little – certainly much less than babies in much of the rest of the world.

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Meeting baby for the first time video - Baby Friendly Initiative

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Baby Friendly’s video on skin-to-skin contact and how it can help mothers and babies get their relationship off to the best start.

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Good birth stories are powerful. Hearing a mother's experience - how she felt, what helped her feel strong, the way they were loved and listened to - it's more than comfort. It's a model to copy.

Learning from first-hand experience gifts you confidence for your birth. And when you also have a story to share, you can pay that forward in turn.

For nine years, tell me a good birth story has been building a big chain of beautiful birth stories. The link gets longer all the time, so if you'd like to add to it, please get in touch. Whether waterbirth or caesarean, induction or a breech birth at home, if you want to contribute your experience as a way to support new parents, contact us using the SHARE YOUR STORY page.

As for how to use this site.....head over to our library and dive in. A scroll's ok. But better still, get yourself a cup of tea and have a proper 'meeting' with the people sharing their stories there. In amongst the tales you'll find some tips from me - pearls and pointers about what all women need, wherever their birth journey takes them.

For further encouragement, my book is packed with practical guidance, and will help provide a clear path to you having a positive birth experience yourself.

Buy a copy, for yourself or a friend, and you'll be supporting our site and helping our community to grow.

'Absolutely loved this book. Very informative and full of no-nonsense, real and realistic advice about giving birth. A fantastic resource for preparing for a positive birth experience, whatever kind of birth you have. On top of that, it is a beautiful book with gorgeous imagery. A joy to read.' Noobug, Amazon Customer

'Natalie is all your mothers, your sisters, your aunties and your friends arriving bearing the gifts of their experience and wisdom. Nothing this book shares with us is useless; every page holds a nugget that could make birth or parenting easier or more beautiful. Reading the section on labour I felt I could hear Natalie's warm, kind voice, holding my hand as she passed on the deep, intuitive knowledge that can only come from years spent accompanying parents through labour and birth.' AIMS ( Association for the Improvement of Maternity Services )

'I adored this book and can't stop recommending it to people. I read it when pregnant with my second child and learnt so much, despite having giving birth before. It made so much sense! I learnt about all the stages of labour and was so much better prepared for my second birth. I loved the suggestions of lavender and hot water bottles, and other tips. It made me feel nurtured and excited about the birth. A very special book!' Jo

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Good birth stories are powerful. Hearing a mother's experience - how she felt, what helped her feel strong, the way they were loved and listened to - it's more than comfort. It's a model to copy. Learning from first-hand experience gifts you confidence for your birth.

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The Birth of Emily Willow   www.rebeccamayphotography.co.uk

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Healthy Children Project
159 Long Pond Drive
Harwich, MA 02645
Ph: 508.888.8044
Fax: 508.888.8050

The First Hour After Birth: A Baby's 9 Instinctive Stages

The first hours after birth are a developmentally distinct time for a baby and there are well documented short and long term physical and psychological advantages when a baby is held skin to skin during this time.

When a baby is in skin to skin contact after birth there are nine observable newborn stages, happening in a specific order, that are innate and instinctive for the baby. Within each of these stages, there are a variety of actions the baby may demonstrate.

Stage 1: The Birth Cry
The first stage is the birth cry. This distinctive cry occurs immediately after birth as the baby's lungs expand.

Stage 2: Relaxation
The second stage is the relaxation stage. During the relaxation stage, the newborn exhibits no mouth movements and the hands are relaxed. This stage usually begins when the birth cry has stopped. The baby is skin to skin with the mother and covered with a warm, dry towel or blanket.
Stage 3: Awakening The third stage is the awakening stage. During this stage the newborn exhibits small thrusts of movement in the head and shoulders. This stage usually begins about 3 minutes after birth. The newborn in the awakening stage may exhibit head movements, open his eyes, show some mouth activity and might move his shoulders.

Stage 4: Activity
The fourth stage is the activity stage. During this stage, the newborn begins to make increased mouthing and sucking movements as the rooting reflex becomes more obvious. This stage usually begins about 8 minutes after birth.

Stage 5: Rest
At any point, the baby may rest. The baby may have periods of resting between periods of activity throughout the first hour or so after birth.

Stage 6: Crawling
The sixth stage is the crawling stage. The baby approaches the breast during this stage with short periods of action that result in reaching the breast and nipple. This stage usually begins about 35 minutes after birth.

Stage 7: Familiarization
The seventh stage is called familiarization. During this stage, the newborn becomes acquainted with the mother by licking the nipple and touching and massaging her breast. This stage usually begins around 45 minutes after birth and could last for 20 minutes or more.

Stage 8: Suckling
The eighth stage is suckling. During this stage, the newborn takes the nipple, self attaches and suckles. This early experience of learning to breastfeed usually begins about an hour after birth. If the mother has had analgesia/anesthesia during labor, it may take more time with skin to skin for the baby to complete the stages and begin suckling.

Stage 9: Sleep
The final stage is sleep. The baby and sometimes the mother fall into a restful sleep. Babies usually fall asleep about 1½ to 2 hours after birth.

Benefits for Babies:
Regardless of how you are feeding your baby, your baby can benefit from skin to skin contact.

Babies are warmer.

Babies are calmer.

Babies can hear their mother's heartbeat.

Heart and breathing rates are normalized.

Milk supply may be improved.

Other family members can hold and bond with babies through skin to skin holding too!

What To Do in the First Hour with Mother

You and your baby are covered with a blanket. The baby's head stays out. The baby is naked and not wrapped. You and your baby will rest skin to skin for an hour or two after birth. This is a special time for you and your baby. Necessary procedures and checks are done with the mother and baby skin to skin.

If there are medical reasons that keep you and your baby from skin to skin holding right after birth, start as soon as possible.

If you are on medications or anything that might impair your strength or ability to stay awake when holding the baby, be sure someone else can help you care for the baby and hold the baby skin to skin.

Kajsa Brimdyr, PhD, CLC
Healthy Children Project
159 Long Pond Drive
Harwich, MA 02645, (508) 888 8044

© Health Education Associates, Inc. Based on the research of Widström, et al.

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When a baby is in skin to skin contact after birth there are nine observable newborn stages, happening in a specific order, that are innate and instinctive for the baby. Within each of these stages, there are a variety of actions the baby may demonstrate.

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In this article

What is an assisted birth?

An assisted birth is when your baby needs help to be born with instruments that attach to her head. It's also called an instrumental, or operative vaginal birth. About one birth in eight is assisted (HSCIC 2013, ISD Scotland 2014, RCOG 2011, 2012).

Assisted births are often needed when labour has been long and tiring, as it can be about helping the mum as well as the baby (NCCWCH 2014). A long slow labour is more likely if you're expecting your first baby (NCCWCH 2014). Based on statistics for England, about one in five first-time mums has an assisted birth compared with one in 14 mums who have had a baby before (HSCIC 2013).

The option of assisted birth helps many first-time mums to achieve a vaginal birth, and puts them in a better position to have a straightforward birth for their next baby (RCOG 2011, 2012) than if they'd had a caesarean (Knight et al 2014, RCOG 2008).

What are forceps and ventouse?

Forceps and ventouse are the instruments used for an assisted birth.

Which instrument is used depends on how close you are to your due date, the position she is in, and how difficult your doctor thinks the birth is going to be (O'Mahony et al 2010, RCOG 2011, 2012).

Forceps look a bit like two stainless steel salad servers that fit together. There is a handle at one end, and the other end has two curves which cradle your baby's head.

The ventouse (vacuum extractor), has a cup attached to a suction device, and a handle to pull on. The cup fits on top and towards the back of your baby's head, and a vacuum is created within the cup. The cup is made of soft or semi-rigid plastic, or metal (O'Mahony et al 2010). The vacuum is created by a hand-held pump or a suction machine.

Ventouse is not recommended if:

Your baby is less than 34 weeks, as her skull will be too soft to cope with the vacuum (RCOG 2011, 2012).

You are having a breech birth.

Your baby is lying face-first (O'Mahony et al 2010, RCOG 2011:4).

Why might I need an assisted birth?

Your midwife and doctor may recommend an assisted birth if:

Your baby is distressed during the pushing stage of labour (NCCWCH 2014).

You are exhausted and can't push any more (NCCWCH 2014).

Your baby isn't making progress through your pelvis as would normally be expected (NCCWCH 2014).

There's a medical reason why you shouldn't push for too long, such as if you suffer from heart disease (RCOG 2012).

Your baby's head needs gently turning, so she's facing the right way to be born (MIDIRS 2008, RCOG 2012).

Can I avoid an assisted birth?

It's not always possible to avoid an assisted birth, but you can reduce your risk when planning your baby's birth and when you're in labour.

If your pregnancy is going well, you should have the option to give birth at home or at a birth centre. Planning to have your baby in either of these places increases your chance of having a straightforward labour and birth, without instruments and other interventions (Hollowell et al 2011, NCCWCH 2014).

Once you're in labour, taking these steps will reduce your risk of needing instruments to help your baby to be born:

Having continuous support from a birth partner or doula.

Having an upright position during labour or lying on your side for the birth rather than on your back.

Not having an epidural.

If you've had an epidural, waiting for at least an hour after you are fully dilated (so that the head can descend further into the birth canal), or until you feel the urge to push, before trying to push your baby out. Using a hormone drip can help too.
(RCOG 2011, 2012)

What happens before an assisted birth?

Your doctor will explain why you need an assisted birth and what your options are (NCCWCH 2014). She'll observe your bump and examine you internally, to check your baby's position and make sure that an assisted birth is the right thing to offer you. She'll then decide which instrument to use and talk this through with you.

If your doctor thinks that an assisted birth is possible, but could be difficult, you will be moved to the operating theatre. This is in case a caesarean is needed. Assisted birth is less likely to be successful if:

Whether you're in a delivery room or in theatre, your legs will be placed in stirrups or supports at either side of the bed, and the end of the bed will be removed.

You'll need an empty bladder, so a thin tube (catheter) attached to a bag may be put in your bladder to empty it. This may be a bit uncomfortable (RCOG 2011: 5).

You'll be given pain relief, which may be an injection inside your vagina (a pudendal block), an epidural, or a spinal anaesthetic (NCCWCH 2014, RCOG 2012). Your baby's heartbeat will be monitored throughout.

A paediatrician is likely to be called to the delivery room. This is normal for an instrumental birth, so try not to worry.

What happens during a ventouse birth?

The doctor or specially trained midwife ventouse practitioner (MVP) will place the ventouse cup on your baby's head, inside your vagina. It may be possible to do this without a cut to your perineum ( episiotomy) to enlarge the opening (O'Mahony et al 2010, Siggelkow et al 2014). The cup fits on the top of your baby's head, rather than around it, so less room may be needed compared with forceps.

Once the cup is in place, the air is sucked out of it, usually with a hand-held pump. Alternatives to a hand-held pump include a foot-controlled vacuum pump or a machine. It can be noisy if a machine is used, so be prepared.

When it is securely fixed, the doctor will ask you to push with your next contraction. Don't worry if you've had an epidural and can't feel your contractions. Your doctor or midwife will know what to look out for and will tell you when to push. She will pull on the cup to help your baby out. Sometimes the cup comes off the baby's head, which even if it sounds alarming, won't cause any harm to your baby.

If your baby isn't moving down with each pull, your doctor should stop the procedure (RCOG 2011: 9). It should also be abandoned if, after three contractions and some good pushing, your baby's still not near to being born (RCOG 2011: 9).

If ventouse is unsuccessful, it may be possible to try using forceps before resorting to a caesarean section (RCOG 2011: 10). However, using different instruments one after the other can increase the risk of injury to your baby (RCOG 2011:10).

What happens during a forceps birth?

Once you have had some form of pain relief, the doctor will examine you internally to check that your baby is looking in the right direction for birth. If you are lying on your back, your baby should be facing the floor.

Your doctor will carry out an episiotomy. This enlarges the opening of your vagina, so the forceps can be applied easily. The doctor will gently apply the forceps one at a time to each side of your baby's head.

The doctor will gently pull with the forceps while you push during a contraction. If you can't feel your contractions because of the pain relief, your midwife will tell you when and where to push. This helps your baby move down through the birth canal. Your doctor may also use forceps to rotate your baby if she is not facing downwards.

If your baby is not moving down with each pull, or isn't born after three contractions and pulls, the forceps should be abandoned. You will then be recommended to have a caesarean (RCOG 2011: 9).

Is ventouse or forceps better?

The two instruments have different risks and benefits, which your doctor or midwife will take into account when discussing your options with you.

When compared with forceps, ventouse is less likely to cause significant damage to your perineum or vagina, but is:

Less likely to be successful at helping your baby to be born.

More likely to leave your baby with a temporary swelling on her head (cephalhaematoma).

More likely to cause bleeding inside your baby's eye (retinal haemorrhage)(O'Mahony et al 2010) although this is uncommon.

When compared with ventouse, forceps are more likely to be successful at helping your baby be born, but are more likely to:

Cause redness or slight bruising on the side of your baby's face.

Involve an episiotomy, a severe tear, or both.

Cause significant damage to your perineum and vagina.

Cause short-term incontinence problems for you, such as being unable to control your bladder, wind or your bowel movements.
(O'Mahony et al 2010)

It may appear that ventouse is the best option, as it causes less trauma to you and your baby. But for some births, forceps are more suitable. Your doctor will explain why.
For example, if your baby needs to be born quickly, forceps are often a better choice. And if your doctor feels a ventouse is unlikely to be successful, it's better to use the forceps straight away. This is because using one instrument then resorting to another, may cause further damage (RCOG 2011: 9).

The instrument that's best suited to your particular circumstances will be selected and recommended to you (RCOG 2011: 8). For you and your baby, long-term recovery after birth is much the same for both methods (RCOG 2011: 9).

What happens after the birth?

Most babies recover from an assisted birth very quickly. Though it may look worrying, any marks, bruises or swellings on your baby's head are usually temporary, and will clear up on their own, usually within a week (RCOG 2012). However, a blood blister may take a few weeks to disappear completely.

If you've had an assisted birth, you will probably want to know more about why it happened. Make a note of anything that's bothering you, whether it's about your labour or birth, or worries about how your baby will recover.

Ideally, the obstetrician or midwife who assisted your birth should talk to you and answer your questions before you're discharged from hospital (RCOG 2011, 2012).

She'll explain why your baby needed help to be born, and any complications that you and your baby may have. She'll also tell you if it might affect your future pregnancies. If you want to talk about what happened when you're back at home with your baby, you should be able to contact a midwife, obstetrician or your GP to arrange this (RCOG 2012).

Be reassured that eight out of 10 women who have an assisted birth have a normal birth next time around (RCOG 2011, 2012).

References

Hollowell J, Puddicombe D, Rowe R, et al. 2011. The Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth Birthplace in England research programme. Final report part 4. NIHR Service Delivery and Organisation programme. www.npeu.ox.ac.uk [Accessed November 2014]

HSCIC. 2013. NHS maternity statistics - England 2012-13. Main tables. Health and Social Care Information Centre. www.hscic.gov.uk [Accessed November 2014]

ISD Scotland. 2014. Births in Scottish hospitals: year ending 31st March 2013. Information Services Division Scotland. www.isdscotland.org [Accessed November 2014]

Knight HE, Gurol-Urganci I, van der Meulen JH, et al. 2014. Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success. BJOG 121(2):183-92. onlinelibrary.wiley.com [Accessed April 2015]

MIDIRS. 2008. Mode of delivery and events around the second stage of labour. MIDIRS Informed Choice - for professionals 16

NCCWCH. 2014. Intrapartum care: care of healthy women and their babies during childbirth. National Collaborating Centre for Women's and Children's Health, Clinical guideline, 190. www.nice.org.uk [Accessed December 2014]

O'Mahony F, Hofmeyr GJ, Menon V. 2010. Choice of instruments for assisted vaginal delivery. Cochrane Database of Systematic Reviews (11): CD005455. onlinelibrary.wiley.com [Accessed November 2014]

RCOG. 2008. Birth after a previous caesarean: information for you. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Accessed April 2015]

RCOG. 2011. Operative vaginal delivery. Royal College of Obstetricians and Gynaecologists, Green-top guideline, 26. London: RCOG press. www.rcog.org.uk [Accessed November 2014]

RCOG. 2012. Information for you: an assisted vaginal birth (ventouse of forceps). Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Accessed November 2014]

Siggelkow W, Schwarz N, Beckmann MW, et al. 2014. Comparison of obstetric efficacy and safety of the Kiwi Omnicup with conventional vacuum extraction. Geburtshilfe Frauenheilkd 74(2):146-151

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In this article An assisted birth is when your baby needs help to be born with instruments that attach to her head. It's also called an instrumental, or operative vaginal birth. About one birth in eight is assisted (HSCIC 2013, ISD Scotland 2014, RCOG 2011, 2012).

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A caesarean section, or C-section, is an operation to deliver your baby through a cut made in your tummy and womb.
The cut is usually made across your tummy, just below your bikini line.

A caesarean is a major operation that carries a number of risks, so it's usually only done if it's the safest option for you and your baby.

Around 1 in 4 pregnant women in the UK has a caesarean birth.

Why caesareans are carried out

A caesarean may be recommended as a planned (elective) procedure or done in an emergency if it's thought a vaginal birth is too risky.

Planned caesareans are usually done from the 39th week of pregnancy.

A caesarean may be carried out because:

your baby is in the breech position (feet first) and your doctor or midwife has been unable to turn them by applying gentle pressure to your tummy, or you'd prefer they did not try this

you have a low-lying placenta (placenta praevia)

you have pregnancy-related high blood pressure (pre-eclampsia)

you have certain infections, such as a first genital herpes infection occurring late in pregnancy or untreated HIV

your baby is not getting enough oxygen and nutrients - sometimes this may mean the baby needs to be delivered immediately

your labour is not progressing or there's excessive vaginal bleeding

If there's time to plan the procedure, your midwife or doctor will discuss the benefits and risks of a caesarean compared with a vaginal birth.

Asking for a caesarean

Some women choose to have a caesarean for non-medical reasons.

If you ask your midwife or doctor for a caesarean when there are not medical reasons, they'll explain the overall benefits and risks of a caesarean to you and your baby compared with a vaginal birth.

If you're anxious about giving birth, you should be offered the chance to discuss your anxiety with a healthcare professional who can offer support during your pregnancy and labour.

If after discussing all the risks and hearing about all the support on offer you still feel that a vaginal birth is not an acceptable option, you should be offered a planned caesarean. If your doctor is unwilling to perform the operation, they should refer you to a doctor who will.

What happens during a caesarean

Most caesareans are carried out under spinal or epidural anaesthetic.

This mean you'll be awake, but the lower part of your body is numbed so you will not feel any pain.

During the procedure:

a screen is placed across your body so you cannot see what's being done - the doctors and nurses will let you know what's happening

a cut about 10 to 20cm long will usually be made across your lower tummy and womb so your baby can be delivered

you may feel some tugging and pulling during the procedure

you and your birth partner will be able to see and hold your baby as soon as they have been delivered if they're well - a baby born by emergency caesarean because of foetal distress may be taken straight to a paediatrician for resuscitation

The whole operation normally takes about 40 to 50 minutes.

Occasionally, a general anaesthetic (where you're asleep) may be used, particularly if the baby needs to be delivered more quickly.
Find out more about how a caesarean is carried out

Recovering from a caesarean

Recovering from a caesarean usually takes longer than recovering from a vaginal delivery.

Providing there are no complications, most women can go home 1 to 2 days after having a caesarean.

You may experience some discomfort in your tummy for the first few days. You'll be offered painkillers to help with this.

When you go home, you'll need to take things easy at first. You may need to avoid some activities, such as driving, until you have had your postnatal check-up with the doctor at 6 weeks.

The wound in your tummy will eventually form a scar. This may be obvious at first, but it should fade with time and will often be hidden in your pubic hair.
Find out more about recovering from a caesarean

Risks of a caesarean

A caesarean is generally a very safe procedure, but like any type of surgery it carries a certain amount of risk.

It's important to be aware of the possible complications, particularly if you're considering having a caesarean for non-medical reasons.

Possible complications include:

infection of the wound or womb lining

blood clots

excessive bleeding

damage to nearby areas, such as the bladder or the tubes that connect the kidneys and bladder

temporary breathing difficulties in your baby

accidentally cutting your baby when your womb is opened

Find out more about the risks of a caesarean

Future pregnancies after a caesarean

If you have a baby by caesarean, it does not necessarily mean that any babies you have in the future will also have to be delivered this way.

Most women who have had a caesarean section can safely have a vaginal delivery for their next baby, known as vaginal birth after caesarean (VBAC).

But you may need some extra monitoring during labour just to make sure everything is progressing well.

Some women may be advised to have another caesarean if they have another baby.

This depends on whether a caesarean is still the safest option for them and their baby.

For more information, read the Royal College of Obstetricians and Gynaecologists leaflet on birth options after previous caesarean section.

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Find out why caesarean sections are carried out, whether you can ask for one, what they involve, and what the risks are.

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Caesarean section | Guidance and guidelines | NICE

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Evidence-based recommendations on caesarean section (C-section) for women who plan or need to have a caesarean section

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We are a global network of individuals and free to attend antenatal groups, linked up by social media. We connect pregnant women together to share stories, expertise and positivity about childbirth. Join us as we meet up, link up and shake up birth!

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

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

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Find out why an episiotomy, a cut between the vagina and anus, might be carried out in labour, how long it'll take to heal, and how to prevent a perineal tear in childbirth.

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This website gives you information, tools and resources to become an active member of your maternity care team and active participant in your care. You may be surprised to know that being fully engaged in your maternity care can make all the difference in the care you get, your experiences and the well-being of both you and your baby.

Having the skills, knowledge and confidence to wisely navigate your maternity care is important because:

The quality of maternity care varies a lot across providers and care settings. The care arrangements you make affect what happens to you and your health.

There is broad agreement that cesareans and many other maternity practices are overused and can cause needless discomfort and harm. Becoming informed and following proven tips can help you avoid these problems.

High-quality research points to many safer, more effective practices for you and your baby. But it can take many years before these practices are reliably provided to women and babies at the point of care. Knowing about and seeking best practices can make a big difference for both of you.

Your baby is counting on you to advocate for her or his best start.

You are embarking on many years of responsibility for managing health care across generations. Pregnancy and birth is an ideal time to develop skills, knowledge and confidence for a lifetime. You've come to the right place!

Stay connected with Childbirth Connection. Get updates.

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This website gives you information, tools and resources to become an active member of your maternity care team and active participant in your care. You may be surprised to know that being fully engaged in your maternity care can make all the difference in the care you get, your experiences and the well-being of both you and your baby.

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Within the first few hours after birth, most healthy newborns will instinctively move to their mother's breast and attach on their own. This video shows early breastfeeding initiation through the j...

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An induced labour is one that's started artificially. Every year, 1 in 5 labours are induced in the UK.

Sometimes labour can be induced if your baby is overdue or there's any risk to you or your baby's health.

This risk could be if you have a health condition such as high blood pressure, for example, or your baby is not growing.

Induction will usually be planned in advance. You'll be able to discuss the advantages and disadvantages with your doctor and midwife, and find out why they think your labour should be induced.

It's your choice whether to have your labour induced or not.

If your pregnancy lasts longer than 42 weeks and you decide not to have your labour induced, you should be offered increased monitoring to check your baby's wellbeing.

Why you might be induced

if you're overdue

if your waters have broken

if you or your baby have a health problem

If you're overdue

Induction will be offered if you do not go into labour naturally by 42 weeks, as there will be a higher risk of stillbirth or problems for the baby.

If your waters break early

If your waters break more than 24 hours before labour starts, there's an increased risk of infection to you and your baby.

If your waters break after 34 weeks, you'll have the choice of induction or expectant management.

Expectant management is when your healthcare professionals monitor your condition and your baby's wellbeing, and your pregnancy can progress naturally as long as it's safe for both of you.

Your midwife or doctor should discuss your options with you before you make a decision.

They should also let you know about the newborn (neonatal) special care hospital facilities in your area.

If your baby is born earlier than 37 weeks, they may be vulnerable to problems related to being premature.

If your waters break before 34 weeks, you'll only be offered induction if there are other factors that suggest it's the best thing for you and your baby.

If you have a health condition or your baby is not thriving

You may be offered an induction if you have a condition that means it'll be safer to have your baby sooner, such as diabetes, high blood pressure or intrahepatic cholestasis of pregnancy.

If this is the case, your doctor and midwife will explain your options to you so you can decide whether or not to have your labour induced.

Membrane sweep

Before inducing labour, you'll be offered a membrane sweep, also known as a cervical sweep, to bring on labour.

To carry out a membrane sweep, your midwife or doctor sweeps their finger around your cervix during an internal examination.

This action should separate the membranes of the amniotic sac surrounding your baby from your cervix. This separation releases hormones (prostaglandins), which may start your labour.

Having a membrane sweep does not hurt, but expect some discomfort or slight bleeding afterwards.

If labour does not start after a membrane sweep, you'll be offered induction of labour.

Induction is always carried out in a hospital maternity unit. You'll be looked after by midwives and doctors will be available if you need their help.

How labour is induced

If you're being induced, you'll go into the hospital maternity unit.

Contractions can be started by inserting a tablet (pessary) or gel into your vagina.

Induction of labour may take a while, particularly if the cervix (the neck of the uterus) needs to be softened with pessaries or gels.

If you have a vaginal tablet or gel, you may be allowed to go home while you wait for it to work.

You should contact your midwife or obstetrician if:

your contractions begin

you have not had any contractions after 6 hours

If you've had no contractions after 6 hours, you may be offered another tablet or gel.

If you have a controlled-release pessary inserted into your vagina, it can take 24 hours to work. If you are not having contractions after 24 hours, you may be offered another dose.

Sometimes a hormone drip is needed to speed up the labour. Once labour starts, it should proceed normally, but it can sometimes take 24 to 48 hours to get you into labour.

What induced labour feels like

Induced labour is usually more painful than labour that starts on its own, and you may want to ask for an epidural.

Your pain relief options during labour are not restricted by being induced. You should have access to all the pain relief options usually available in the maternity unit.

If you are induced you'll be more likely to have an assisted delivery, where forceps or ventouse suction are used to help the baby out.

If induction of labour does not work

Induction is not always successful, and labour may not start.

Your obstetrician and midwife will assess your condition and your baby's wellbeing, and you may be offered another induction or a caesarean section.

Your midwife and doctor will discuss all your options with you.

Natural ways to start labour

There are no proven ways of starting your labour yourself at home.

You may have heard that certain things can trigger labour, such as herbal supplements and having sex, but there's no evidence that these work.

Other methods that are not supported by scientific evidence include acupuncture, homeopathy, hot baths, castor oil and enemas.

Having sex will not cause harm, but you should avoid having sex if your waters have broken as there's an increased risk of infection.

For more information on induction, you can read the NICE information for the public on induction of labour.

You can find pregnancy and baby apps and tools in the NHS apps library.

Community content from HealthUnlocked

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An induced labour is one that's started artificially. Every year, 1 in 5 labours are induced in the UK. Sometimes labour can be induced if your baby is overdue or there's any risk to you or your baby's health.

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information, inspiration and illumination for midwives, birth folk, women and families ...

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This guideline has been updated and replaced by inducing labour

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What to expect after your baby is born, including information on skin-to-skin contact, bonding, stitches and vitamin K injections.

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What is an episiotomy?

An episiotomy is a cut to a woman's perineum (skin between the vagina and anus) made by a doctor or midwife during childbirth. Episiotomies help to make the vaginal opening wider to allow the baby through more easily. The procedure is only performed when there is a medical reason to do so (NICE, 2014).

What is the difference between an episiotomy and a perineal tear?

An episiotomy is a cut made by a health professional, while a perineal tear happens on its own during the second stage of labour. When a baby is being born, the perineum needs to stretch a lot and sometimes tears on its own.

How common are tears and episiotomies?

More than 85% of women who have a vaginal birth have some kind of tear or episiotomy (Frolich and Kettle, 2015). In first-time vaginal births, you're more likely to have worse injuries if the perineum tears on its own than if you get an episiotomy (NHS Choices, 2017).

At least one third of women in the UK and US have perineal tears that need stitches (Frolich and Kettle, 2015). About three in 100 women having a vaginal birth have the more severe perineal tears. Tears are slightly more common with a first vaginal birth than in women who have had a vaginal birth before (RCOG, 2015b).

Can perineal massage reduce my risk of tearing?

Some evidence suggests massaging the perineum in the last weeks of pregnancy might reduce the likelihood of tearing or needing an episiotomy or stitches (Beckmann and Stock 2013). For more information on how to do it, see our article on perineal massage.

What to expect during an episiotomy

If you need an episiotomy during childbirth, you will be offered pain relief and will be given stitches afterwards. It's usually a straightforward procedure.

For pain relief, you'll have local anaesthetic applied to numb the area. If you've had an epidural, the dose can be topped up as needed.

The cut your doctor or midwife makes will be small and diagonal. It'll go from the back of the vagina, down and out to one side.

The doctor or midwife will stitch up the cut after your baby is born. They'll use dissolvable stitches. (NICE, 2014; NHC Choices, 2017)

When might I need an episiotomy?

You might need an episiotomy if:

Forceps or ventouse are required to help you give birth to your baby.

Your baby is in distress (their heart rate gets much faster or slower) and they need to be born quickly.

You have been trying to give birth for several hours and are worn out from pushing.

You're having a breech birth - your baby is not head-first.

You have a serious health condition that requires your baby's birth to be as quick as possible to minimise risks to you. (NICE, 2014; NHS Choices, 2017)

An episiotomy might prevent more severe tears in some births, particularly in those where forceps are used (NHS Choices, 2017).

Recovery from episiotomy

Episiotomy cuts are usually stitched up within an hour of your baby's birth.

The cut might bleed quite a lot to start with, but this should stop with pressure and stitches.

Your stitches should heal within one month of your baby's birth. (NHS Choices, 2017)

Talk to your midwife or GP about which activities you should avoid during the healing period. Read more in our article on episiotomy recovery.

If you are concerned about how you are healing following a perineal tear or episiotomy, it's important to talk to a health professional. You can then get treatment if required.
This page was last reviewed in August 2018
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.

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

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

The Royal College of Obstetricians and Gynaecologists (RCOG) has an information hub for perineal tears and episiotomies in childbirth. You can find out more about the types of tears that can occur during childbirth, how to minimise your risk of deeper tearing, and what can be done to help your recovery if you do tear. It also covers what to do if you have any concerns about your recovery, helping you feel better informed when discussing any topics with a healthcare professional.

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].

Frolich J, Kettle C. (2015) Perineal care. BMJ Clin Evid. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356152/[Accessed 16th May 2017].

NHS Choices. (2017) Episiotomy and perineal tears. Available from: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/episiotomy.aspx [Accessed 16th May 2017].

NICE. (2014) Intrapartum care for healthy women and babies. Available from: https://www.nice.org. uk/guidance/cg190 [Accessed 16th May 2017].

RCOG. (2015a) The management of third- and fourth-degree perineal tears. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf [Accessed 16th May 2017].

RCOG. (2015b) A third of fourth degree tear during birth (also known as obstetiric anal sphincter injury - OASI). Available from: https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-third--or-fourth-degree-tear-during-birth.pdf [Accessed 16th May 2017].

RCOG. (2016) Patterns of maternity care in English NHS trusts 2013/14. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/research--audit/maternity-indicators-2013-14_report2.pdf [Accessed 16th May 2017].

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An episiotomy is a cut to a woman's perineum (skin between the vagina and anus) made by a doctor or midwife during childbirth. Episiotomies help to make the vaginal opening wider to allow the baby through more easily. The procedure is only performed when there is a medical reason to do so (NICE, 2014).

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Baby-friendly caesarean birth | Maidstone and Tunbridge Wells NHS Trust

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Watch our video for information about formula milk.

What is infant formula?

Infant formula is intended as a substitute for parents who cannot or decide not to breastfeed their babies. Its formula aims to mimic the nutritional composition of breast milk (Martin et al, 2016).

Is powdered or ready-made formula better?

Infant formula normally comes in two different forms: a dry powder that you mix with water, or a ready to feed liquid formula. There is little compositional difference between the two but ready to feed milks tend to be more expensive and use more packaging (Martin, 2016; NHS Choices, 2016; Crawley, 2018; Crawley and Westland, 2019). The ingredients used vary between manufacturers, and there might also be differences from batch to batch.

What ingredients are in infant formula?

Most infant milks start with a base of cows' milk or goats' milk as skimmed or full-fat, liquid or powder, or using demineralised whey protein concentrates. Lactose or other carbohydrates, vegetable, fish and other oils, vitamins and minerals are all added to the milk base (Crawley and Westland, 2019).

The basic components of any infant milk, regardless of the format (powder or ready-to-feed), are proteins, fats, carbohydrates, vitamins and minerals (Crawley and Westland, 2019). The major infant formula producers develop their own brands with a combination of each of these components. You can see a full list of constituents on the packaging for infant formula milk for babies (Crawley, 2018).

Which formula milk nutrients are best?

If a substance has proven benefits for your baby and can be added to infant formula, the law requires it to be added to all formula (Crawley, 2018). So buying a more expensive brand of formula does not mean that your baby will grow or develop better than if you were buying a cheaper one. The basic nutritional profile of the majority of infant milks is actually very similar (NHS Choices, 2016; Crawley and Westland, 2019).

In the UK, the ingredients in infant formula are strictly regulated and each manufacturer must follow strict national and EU guidelines on composition (Martin, 2016). Formula producers have to add formula milk components in accordance with the regulatory framework of the Infant Formula and Follow-on Formula Regulations 2007. They also have to comply with any relevant changes to those regulations and to regulations around foods for special medical purposes.

Which formula milk is best?

For a healthy, full-term baby, it really doesn't matter which brand you choose. They all make various claims and have different ingredients. Yet regardless of their cost, like we said, all brands have to meet the same nutritional and safety standards and have a relatively similar composition (Martin, 2016; Crawley, 2018).

First Steps Nutrition Trust has more information here on the different brands of formula milk available in the UK and their ingredients. We also have an article here about the different types of formula milk.

Can I change the formula my baby has?

Traditionally, parents were advised to stick to one brand, but there's no good evidence that changing does any harm (NHS Choices, 2016; Crawley, 2018). You can try different formulas to see which your baby might prefer in case the small variations in ingredients have an effect.

As manufacturers sometimes change ingredients slightly from batch to batch, it may be that one brand no longer agrees with your baby. Do talk to your healthcare professional if you'd like to change brands (NHS, 2016). A few babies may do better with a special formula instead of the regular kind but this needs medical advice.

Is formula vegetarian or vegan?

Only certain formulas are vegetarian as many contain fish oils and/or animal rennet. Information on suitable formulas is available here from First Steps Nutrition trust.

Soya-based formulas are suitable for vegetarians but are not recommended for babies under six months old except under medical supervision (Crawley and Westfield, 2019). There are currently no infant milks suitable for vegans in the UK as even those without animal proteins contain vitamin D from sheep's wool.

It is recommended that those who follow a vegan diet breastfeed throughout the first year of life and can move their children onto a non-animal milk at one year of age (Crawley and Westfield, 2019). Parents who want to bring up their children as vegans should seek medical advice to ensure their nutritional needs are being met (Crawley and Westfield, 2019).

How does formula milk compare to breastmilk for my baby's health?

When formula is prepared safely, it provides babies with the nutrients they need to grow and develop (Martin, 2016; Crawley and Westfield, 2019). Yet formula milk cannot offer many of the same health benefits as breastfeeding, such as protection from infections and other illnesses (Martin, 2016). This is because living cells, hormones and friendly bacteria cannot be replicated by a man-made process (Crawley, 2018).

Can I use formula and continue to breastfeed?

If you continue to breastfeed as well as feed formula, your breastmilk will continue to offer benefits to your baby (Crawley, 2018). Milk supply is generally driven by frequent, effective breastfeeding. Giving your baby formula can have an impact on this, because it may mean your baby breastfeeds less often, and therefore you make less milk.

Read our article about mixed feeding to find out more. You may also find it useful to talk through your options with your midwife, health visitor or breastfeeding counsellor. You can also contact one of our friendly and knowledgeable breastfeeding counsellors by calling our Infant Feeding Support Line on 0300 330 0700. They're open between 8am and midnight every day.

How do I make up powdered formula?

As powdered formula is not sterile, it is important that it's made up correctly each time, using boiled water that has cooled for no more than 30 minutes. To kill any bacteria within the powder, it is important that the water is at least 70⁰C (NHS, 2016).

Safe preparation is key - all formula have to be made using the right amount of powder as diluting or using too much powder could make your baby unwell (NHS, 2015). See our step-by-step guide to preparing baby formula and how to make up a bottle if you're out for more details.
This page was last reviewed in May 2019.
Further information

We support all parents, however they feed their baby. If you have questions, concerns or need support, you can speak to a breastfeeding counsellor by calling our helpline on 0300 330 0700, whether you are exclusively breastfeeding or using formula milk. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions. You can also find more useful articles here.

For more detailed information on the different formula milks that are available, visit First Steps Nutrition Trust.

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Watch our video for information about formula milk. Infant formula is intended as a substitute for parents who cannot or decide not to breastfeed their babies. Its formula aims to mimic the nutritional composition of breast milk (Martin et al, 2016).

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Elective or Emergency Caesarean

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Breastfeeding - what you need to know

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Handy tips for bottle feeding your baby, including hygiene, being prepared, how to wind your baby and how to keep them safe.

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Many of you requested repeated access to our first webinar series. The Foundations of Biological Nurturing. We appreciate your comments. In this series, Advanced Biological Nurtuirng: Womb to World, for your convenience, if you miss the live sessions, you can view the live presentation from a secure website for as many times as you want for 2 weeks afterwards.

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What if I need to formula feed my baby away from home? | Baby & toddler, Feeding articles & support | NCT

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Here we explain how to prepare a bottle for going out and how to make up formula safely when you are out...

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You feel like you've swallowed a whole watermelon and getting anywhere feels like a feat of Herculean proportions. Your baby must surely be ready to come out, right?

You're definitely not alone if you've been focusing on your due date throughout your pregnancy and counting down to it in the latter stages. And it's understandable that you might feel disappointed or worried if you go past that date with no sign of your baby.

So when might you be offered treatment for an overdue baby and what happens? Well, the story starts with the due date...

When is a baby overdue or late?

Pregnancy normally lasts about 40 weeks, and that's when it's called a full-term pregnancy or term. This is calculated as 280 days from the first day of your last menstrual period (IQWiG, 2018).

A pregnancy that continues for longer than 42 weeks is called post-term, prolonged or overdue (IQWiG, 2018). Many heavily-pregnant, exhausted mums-to-be have a few choice names for it themselves!

How accurate are due dates?

It depends. Using early ultrasound scans rather than the date of the last menstrual period can be a better way to predict your due date (Whitworth et al, 2015). One study suggested that 55% of women gave birth within seven days either side of the due date predicted by ultrasound, and 70% of women gave birth within 10 days either side of that date (Mongeli et al, 1996).

When pregnancies are dated by ultrasound (and not induced), one study suggested that 7% of pregnancies progress beyond 294 days (42 weeks) and 1.4% beyond 301 days (43 weeks) (Mandruzatto, 2010).

Why are some babies overdue or late?

We don't fully understand why some babies are overdue. You might be more likely to have an overdue baby if you're older, heavier, more educated, expecting your first baby or having a boy (Oberg et al, 2013). You're also more likely to have an overdue baby if your mum or sister had this too (Oberg et al, 2013).

What is a membrane sweep?

If your baby is overdue, the first thing you might be offered is a membrane sweep. The membrane sweep makes it more likely that you will go into labour naturally. So it reduces the chances you'll need to have your labour induced by other means, such as oxytocin or prostaglandins.

If this is your first pregnancy, you should be offered a membrane sweep at your 40 and 41 week appointments. If you've already had a baby before, you will be offered a sweep at your 41 week appointment (NICE, 2008a).

Although a sweep is offered, you don't have to accept the offer. Healthcare professionals should support you in whatever decision you make (NICE, 2008a).

What happens during a membrane sweep?

During a sweep, the midwife will put a finger inside your vagina to reach the cervix. They will make a circular or sweeping movement with their fingers. The point of it is to separate the sac surrounding your baby from the cervix. Doing a sweep helps to release natural hormones that stimulate contractions, so it may get labour started. A membrane sweep can be uncomfortable for some women and there may be some vaginal bleeding afterwards (Tommy's, 2015).

Membrane sweeps have been shown to increase the likelihood of either spontaneous labour within 48 hours or delivery within one week. They are generally safe where there are no other complications.

Membrane sweeps can be uncomfortable, and can cause bleeding and irregular contractions. You have to consider these factors against being more likely to need a more formal method of induction later down the line.

How likely is a membrane sweep to start labour?

Just because you have a membrane sweep, it doesn't mean that labour will happen spontaneously. In fact, only one out of eight women who have a membrane sweep avoid formal induction of labour (Boulvain et al, 2005).

If labour doesn't start after this process, you can have multiple sweeps or you may be offered an induction of labour by other means.

Can I do anything to start labour myself?

For mums who'd prefer to have some control over the process, there are traditional ways of trying to induce labour at home. See more in our article about whether you can really kick-start your own labour or not.

What is induced labour?

Labour is a natural process that usually starts on its own. But sometimes labour needs to be started artificially. This is called 'induced labour' (NICE, 2008a).

When and why would I be offered an induction?

Induction of labour is offered in the following conditions:

If a pregnancy lasts longer than 42 weeks, because of the increased risk of stillbirth and complications of labour.

If an expectant mum's waters break but labour does not start.

If you have specific conditions, such as diabetes, high blood pressure, obstetric cholestasis or pre-eclampsia.

If there are concerns about the growth of your baby and your healthcare team feel this would be the safest option for you and your baby.

You are also likely to be offered an induction of labour in the tragic event of your baby dying in the womb.

In special circumstances, induction may be considered at the mum's request.

(NICE, 2008; Thomas et al, 2014).

Around 95% of women who are full term and whose waters break will go into labour within the next 24 hours (Middleton, 2017). If you're not in labour after 24 hours of your waters breaking, you should be offered a choice of induction or waiting for labour to start naturally (expectant management) (NICE, 2008a).

If after 24 hours you're still not in labour, your baby may have a lower risk of infection and of being admitted to a neonatal unit if you're induced (Middleton, 2017).

What happens in an induction of labour?

Induction of labour can be carried out in a hospital maternity unit in different ways.

One way is by inserting hormones such as prostaglandins as a tablet (pessary) or gel into the vagina. Prostaglandins are hormones produced in the body (Thomas et al, 2014). Prostaglandins are used in inductions to encourage the cervix to soften, shorten and open, and the uterus to start to contract regularly (Thomas et al, 2014).

Contractions after vaginal prostaglandins have been inserted usually begin within a few hours, reaching a peak after five to six hours (NICE, 2008a). They increase the likelihood of vaginal birth within 24 hours (Thomas et al, 2014).

Many hospitals may be happy for you to go home after the procedure if you are induced via a pessary, tablet or gel (Sharp et al, 2016). They should let you know who to contact if you have any concerns (NICE, 2014). If you don't begin to have contractions, you might be offered another tablet or gel (NICE, 2008a).

What happens if the prostaglandins don't work?

If labour doesn't start after you've been given prostaglandins, other hormones such as oxytocin may be used. Oxytocin is released naturally from the pituitary gland, stimulating the contraction of the uterus during labour (NICE, 2008a). An artificial form can be swallowed, inserted into the vagina in the form of tablets or fed into a vein using an IV drip (IQWiG, 2018).

Along with other methods of induction, your midwife might ask to break your waters themselves. This is called an artificial rupture of the membranes and its aim is to shorten your labour. Yet this should not be offered routinely as a primary method of induction on its own as there may be some risks (such as infections) (NICE, 2008a; Tommys 2019).

Double balloon catheters can also be used to safely induce labour in pregnant women who have not had a previous caesarean section. A double balloon catheter is another way to try to help the cervix to soften and dilate.

If a double balloon catheter is used to induce your labour, the catheter is inserted so that one balloon is in your uterus and one is in your vagina. The balloons are slowly and alternately inflated with saline. The device is left in place for up to about 12 hours and removed if labour begins, the device comes out, the waters break, or the baby seems to be in distress (NICE, 2015).

What happens once labour starts?

Once you're in labour, you'll be offered a check of your baby's heart rate every so often (NICE, 2008b). If you have certain risk factors, you'll be offered continuous electronic foetal heart rate and uterine contraction monitoring (NICE, 2008b).

Is it more painful to induce labour?

Induced labour is likely to be more painful than spontaneous labour. So you should be offered appropriate pain relief (Kelly and Tan, 2001; NICE, 2008a). This can range from simple pain relief, such as distraction, aromatherapy, hypnotherapy, acupuncture, to an epidural (NICE, 2014). You should be encouraged to use your own coping skills too, and birth attendants should offer support; ideally, you'd also be offered the opportunity to labour in water (NICE, 2008a)

Labour after induction may be more painful because a labour that starts spontaneously usually builds up gradually, giving you time to get used to each new sensation. You get used to the sensation because your body has the chance to release pain-relieving substances called endorphins.

How else does induction affect labour?

The amount of monitoring used in induced labour means that a woman's movement may be restricted. On the other hand, some women like induction because it enables them to have control over knowing roughly when their baby will be born. They also feel reassured that they'll be closely monitored throughout (Wickham, 2018).

Induction at or beyond term might lead to a reduced rate of caesarean section but a slightly higher rate of instrumental birth with forceps or ventouse.

What happens if labour induction doesn't work?

If your induction does not work, your midwife or doctor will discuss other options with you and support you. Other options include another attempt to induce labour or having a caesarean section (NICE, 2008a). Your wellbeing should be considered and the wellbeing of your baby should be assessed using electronic fetal monitoring (with your consent).
This page was last reviewed in June 2018.
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 labour and life with a new baby.

Information from NHS choices on being overdue and on induced labour.

Find out more about NICE guidance on the induction of labour

Boulvain M, Stan M, Irion O. (2005) Membrane sweeping for induction of labour. Cochrane Database of Systematic Reviews. (1):CD000451. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000451.pub2... [accessed 2nd January 2019]

IQWiG (Institute for Quality and Efficiency in Health Care). (2018) Informed health online: pregnancy and birth: when your baby's due date has passed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK279571/. [accessed 3rd January 2019].

Kelly A, Tan B. (2001) Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. (3):CD003246. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003246/epdf... [accessed 2nd January 2019]

Middleton P, Shepherd E, Flenady V, McBain R, Crowther C. (2017) Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews. (1):CD005302. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005302.pub3... [accessed 2nd January 2019]

NICE. (2008a) Inducing labour [CG70]. Available at: https://www.nice.org.uk/guidance/cg70/resources/inducing-labour-pdf-975... [accessed 3rd January 2019]

NICE. (2008b) Antenatal care for uncomplicated pregnancies [CG62]. Available at: https://www.nice.org.uk/guidance/cg62/resources/antenatal-care-for-unco... [accessed 2nd January 2018]

NICE. (2014) Inducing labour (QS60). Available at: https://www.nice.org.uk/guidance/qs60/chapter/Quality-statement-2-Safet... [accessed 3rd January 2019]

NICE. (2015) Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section (IPG528). Available at: https://www.nice.org.uk/guidance/ipg528/ifp/chapter/The-procedure [accessed 3rd January 2019]

Oberg A, Frisell T, Svensson A, Iliadou A. (2013) Maternal and fetal genetic contributions to postterm birth: familial clustering in a population-based sample of 475,429 Swedish births. American Journal of Epidemiology. 177(6):531-537. Available at: https://academic.oup.com/aje/article/177/6/531/160108 [accessed 3rd January 2019]

Sharp A, Stock S, Alfirevic Z. (2016) Outpatient induction of labour in the UK: a survey of practice. European Journal of Obstetrics and Gynaecology and Reproductive Biology. 204:21-23 Available at: https://www.ejog.org/article/S0301-2115(16)30305-0/fulltext [accessed 3rd January 2019]

Thomas J, Fairclough A, Kavanagh J, Kelly A. (2014) Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database of Systematic Reviews. (6):CD003101. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003101.pub3... [accessed 3rd January 2019]

Tommy's. (2015) What is a membrane sweep? Available at: https://www.tommys.org/pregnancy-information/labour-birth/what-membrane.... [accessed 3rd January 2019].

Whitworth M, Bricker L, Mullan C. (2015) Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews. (7):CD007058. Available at: https://www.cochrane.org/CD007058/PREG_routine-compared-selective-ultra... [accessed 3rd January 2019]

Wickham S. (2018) Inducing Labour: Making Informed Decisions. 2nd ed. UK: Birthmoon.
Further reading
Caughey A, Stotland N, Washington A, Escobar G. (2007) Maternal and obstetric complications of pregnancy are associated with increasing gestational age at term. American Journal of Obstetrics and Gynecology. 196(2):155. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1941614/ [accessed 2nd January 2019]

Decker R. (2019) The evidence on: due dates. Available at: https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-pas... [accessed 2nd January 2019]

Kavanagh J, Kelly A, Thomas J. (2005) Breast stimulation for cervical ripening and induction of labour. Cochrane Database of Systematic Reviews. (3):CD003392. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003392.pub2... [accessed 3rd January 2019]

Mandruzzato G, Alfirevic Z, Chervenak F, Gruenebaum A, Heimstad R, Heinonen S, Levene M, Salvesen K, Saugstad O, Skupski D, Thilaganathan B. (2010) Guidelines for the management of postterm pregnancy. Journal of Perinatal Medicine. 38(2010):111-119. Available at: https://pdfs.semanticscholar.org/7e17/c75025c5476e37e98d9372605f026873f... [accessed 3rd January 2019]

Middleton P, Shepherd E, Crowther C. (2018) Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews. (5):CD004945 . Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004945.pub4... [accessed 2nd January 2019]

Mongelli M, Wilcox M, Gardosi J. (1996) Estimating the date of confinement: ultrasonographic biometry versus certain menstrual dates. American Journal of Obstetrics and Gynecology. 174(1):278-281. Available at: https://www.ajog.org/article/S0002-9378(96)70408-8/fulltext [accessed 3rd January 2019]

Morken N, Klungsøyr K, Skjaerven R. (2014) Perinatal mortality by gestational week and size at birth in singleton pregnancies at and beyond term: a nationwide population-based cohort study. BMC Pregnancy and Childbirth. 14(172). Available at: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-... [accessed 2nd January 2019]

NHS Digital. (2018) NHS maternity statistics, England 2017-18. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/nh.... [accessed 3rd January 2019].

NICE. (ND). Dinoprostone. Available at: https://bnf.nice.org.uk/drug/dinoprostone.html [accessed 3rd January 2019]

NICE. (NDb). Oxytocin. Available at: https://bnf.nice.org.uk/drug/oxytocin.html#sideEffects. [accessed 3rd January 2019].

Rosenstein M, Cheng Y, Snowden J, Nicholson J, Doss A, Caughey A. (2012) The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. American Journal of Obstetrics and Gynecology. 206(4):309. Available at: https://www.ajog.org/article/S0002-9378(12)00026-9/fulltext [accessed 3rd January 2019]

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Overdue baby - what happens if my baby is late? | Labour & birth articles & support | NCT

# data[].attributes.attachment_link.description
You feel like you've swallowed a whole watermelon and getting anywhere feels like a feat of Herculean proportions. Your baby must surely be ready to come out, right? You're definitely not alone if you've been focusing on your due date throughout your pregnancy and counting down to it in the latter stages.

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Bottle Feeding