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Support your mental health during COVID-19

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Support your mental health during COVID-19

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Maternal Mental Health Alliance

Also available in Welsh:

Royal College of Psychiatrists

You might be worried about how COVID-19 and the news around it can affect your pregnancy, your baby or your mental health. This resource is for any woman who is planning a pregnancy, is pregnant or has recently had a baby and is worried about her mental health during the COVID-19 outbreak. It's also for their partners, families and friends.

Perinatal Mental Health Partnership UK

Facebook page hosted by the Perinatal Mental Health Partnership UK, offering information for parents about staying well and managing mental health problems during pregnancy and after having a baby.

PANDAS

Mental health support for pregnant and new parents. PANDAS offer a free helpline 0808 1961 776 and email support Monday-Sunday offering signposting and a listening ear for parents experiencing mental health difficulties during pregnancy or after having a baby.

Centre for Interactive Mental Health Services - Bliss

Bliss is an 8 session interactive online therapy program for depression that you complete on your own. The program is based on psychotherapy treatment called cognitive behavioural therapy or CBT for short. CBT has been shown to be effective treatment for depression. The program is designed to teach you techniques that have been shown to be effective at improving your mood and mental health.

Anxiety UK

Anxiety UK - advice and helpline. Anxiety UK offer support for individuals experiencing anxiety and have a dedicated service for people experiencing increased leveld of anxiety as a result of Coronavirus. The site offers practical advice and online support including access to psychological therapies.

OCD Action

Information, telephone and email support for anyone affected by Obsessive Compulsive Disorder

No Panic

No Panic is a registered charity that helps and supports those living with Panic Attacks, Phobias, Obsessive Compulsive Disorders and other related anxiety disorders.

The helpline 0300 772 9844 operates every day 10am to 10pm

PND and Me

Twitter Chat by @PNDandme every Wednesday 8-9pm and on Facebook. A very popular forum providing peer support for mothers and fathers during pregnancy and after having a baby who are experiencing difficulties with their emotional and mental health.

Action on PostPartum Psychosis

APP provide evidence-based information and support for families who have experience of postpartum psychosis or who feel they or a family member is experiencing symptoms of postpartum psychosis. This guidance offers information about accessing services, support and treatment during the Coronavirus outbreak.

This Mum Moves

We know there is a lot for you to think about during pregnancy and motherhood without having to worry about how active you should be and what's safe for you to do.

This Mum Moves is here to help guide you on your way - with online workouts for pregnant women and new mums.

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**Parenting and the COVID-19 pandemic** - IHV

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You are not alone The iHV is dedicated to supporting the health and wellbeing of all families and we have put together links and resources from trusted organisations and websites to support you during the COVID-19 pandemic. This page is being regularly reviewed and updated.

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Guidance for pregnant women

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Access the web version of the guidance on the MAGICapp platform
Version 16.0: updated Thursday 15 December 2022. Guidance for healthcare professionals on coronavirus (COVID-19) infection in pregnancy, including guidance on vaccination in pregnancy, published by the RCOG, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Public Health Scotland. Updates made to this guidance are detailed within the document.

This document is for healthcare professionals.

We have also prepared information for pregnant women and their families, drawn from this guidance.

Further information for healthcare professionals and pregnant women eligible for COVID-19 vaccination is available from our COVID-19 vaccines and pregnancy page.

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Coronavirus (COVID-19), infection in pregnancy

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Access the web version of the guidance on the MAGICapp platform Version 16.0: updated Thursday 15 December 2022. Guidance for healthcare professionals on coronavirus (COVID-19) infection in pregnancy, including guidance on vaccination in pregnancy, published by the RCOG, Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Public Health Scotland.

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NHS information including statistics helping you decide where to give birth

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NHS information including statistics helping you decide where to give birth

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A useful tool to help you decide where to give birth. 

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A useful tool to help you decide where to give birth. 

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Find the right place for you to give birth, based on your preferences and personal circumstances. Our tool suggests the best maternity options for you to discuss with your midwife.

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From The Positive Birth Book

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A birth plan is a record of what you would like to happen during your labour and after the birth. You don't have to create a birth plan but, if you would like one, your midwife will be able to help.

Discussing a birth plan with your midwife gives you the chance to ask questions and find out more about what happens in labour.

It also gives your midwife the chance to get to know you better, and understand your feelings and priorities, and allows you to think about or discuss some things more fully with your partner, friends and relatives.

You can change your mind about your wishes for labour and birth at any time.

Your personal circumstances

Your birth plan is personal to you. It depends on what you want, your medical history, your circumstances and what is available at your maternity service.

You might be given a special form for your birth plan, or there may be room in your notes. It's a good idea to keep a copy of your birth plan with you.

The maternity team who care for you during labour will discuss it with you so they know what you want.

Be flexible

You need to be flexible and prepared to do things differently from your birth plan if complications arise with you or your baby, or if facilities such as a birth pool aren't available.

The maternity team will tell you what they advise in your particular circumstances. Don't hesitate to ask questions if you need to.

Things to consider

You can find out more about the things you need to think about when making a birth plan, such as:

You can work out whether there's anything you feel strongly about and might wish to include.

You can also show your birth partner these tips to support you.

Download a birth plan template

You can download a birth plan template to fill in and save.

Get Start4Life pregnancy and baby emails

Sign up for Start4Life's weekly emails for expert advice, videos and tips on pregnancy, birth and beyond.

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A birth plan is a record of what you would like to happen during your labour and after the birth. You don't have to create a birth plan but, if you would like one, your midwife will be able to help.

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Video of different women's birthing experiences 

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Video of different women's birthing experiences 

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Slow dance of birth

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Turn Off SafeSearch

Turning SafeSearch off may result in the display of Web, Video and Image search results of a mature or sexually explicit nature. By clicking "I Accept," you certify that you are at least 18 years old and agree to the Terms of Service.

Learn more about protecting children online

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slow dance video birth - Yahoo Video Search Results

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Turning SafeSearch off may result in the display of Web, Video and Image search results of a mature or sexually explicit nature. By clicking "I Accept," you certify that you are at least 18 years old and agree to the Terms of Service. Learn more about protecting children online

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Watching women give birth can be a daunting prospect if you’ve never seen it before. The positive birth movement have selected some films which they think will inspire rather than scare you.

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Watching women give birth can be a daunting prospect if you've never seen it before. We've hand selected some films which we think will inspire rather than scare you. If you want us to add a film, please get in touch.

Please note: this next film shows the baby's head emerging as a woman gives birth 'with joy'.

#BirthJustHappened - a collection of images taking in the moments just after birth

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Watch Birth Films | Positive Birth Movement

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Watching women give birth can be a daunting prospect if you've never seen it before. We've hand selected some films which we think will inspire rather than scare you. If you want us to add a film, please get in touch. Please note: this next film shows the baby's head emerging as a woman gives ...

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Know the signs

There are several signs that labour might be starting, including:

contractions or tightenings

a "show", when the plug of mucus from your cervix (entrance to your womb, or uterus) comes away

backache

an urge to go to the toilet, which is caused by your baby's head pressing on your bowel

your waters breaking

The early (latent) stage of labour can take some time.

Coronavirus (COVID-19) update

If you're well, it's really important you go to all your appointments and scans for the health of you and your baby.

If you're pregnant, hospitals and clinics are making sure it's safe for you to go to appointments.

If you get symptoms of COVID-19, or you're unwell with something other than COVID-19, speak to your midwife or maternity team. They will advise you what to do.
Find out more about pregnancy and COVID-19

Latent phase of labour

The start of labour is called the latent phase. This is when your cervix becomes soft and thin, and starts opening for your baby to be born. This can take hours or sometimes days.

You'll probably be advised to stay at home during this time. If you go to the hospital or maternity unit, they may suggest you go back home.

Find out more about the stages of labour and what you can do at home during the latent phase.

Call your midwife if you're unsure or worried about anything.

What do contractions feel like

When you have a contraction, your womb tightens and then relaxes. For some people, contractions may feel like extreme period pains.

You may have had contractions during your pregnancy, particularly towards the end. These tightenings are called Braxton Hicks contractions and are usually painless.

Your contractions tend to become longer, stronger and more frequent as your labour progresses. During a contraction, the muscles tighten and the pain increases. If you put your hand on your abdomen, you'll feel it getting harder; when the muscles relax, the pain fades and you will feel the hardness ease.

The contractions are pushing your baby down and opening the entrance to your womb (the cervix), ready for your baby to go through.

Your midwife will probably advise you to stay at home until your contractions become frequent.

Call your midwife or maternity unit for guidance when your contractions are in a regular pattern and:

last at least 60 seconds

come every 5 minutes or

you think you are in labour

Read more information on when to go to hospital

Backache often comes on in labour

You may get backache or a heavy, aching feeling.

A "show" can signal the start of labour

During pregnancy, there's a plug of mucus in your cervix. This mucus comes away just before labour starts, or when in early labour, and it may pass out of your vagina. This sticky, jelly-like pink mucus is called a show.

It may come away in 1 blob or in several pieces. It's pink because it contains a small amount of blood.

If you're losing more blood, it may be a sign something is wrong, so phone your hospital or midwife straight away.

A show indicates that the cervix is starting to open. Labour may quickly follow or may take a few days. Sometimes there is no show.

What happens when my waters break

It's likely your waters will break during labour, but it can also happen before labour starts.

Your baby develops and grows inside a bag of fluid called the amniotic sac. When it's time for your baby to be born, the sac usually breaks and the amniotic fluid drains out through your vagina. This is your waters breaking. Sometimes when you're in labour, a midwife or doctor may offer to break your waters.

If your waters break naturally, you may feel a slow trickle or a sudden gush of water you cannot control. To prepare for this, you could keep a sanitary towel (but not a tampon) handy if you're going out, and put a protective sheet on your bed.

Amniotic fluid is clear and pale. Sometimes it's difficult to tell amniotic fluid from urine. When your waters break, the water may be a little bloodstained to begin with.

Tell your midwife immediately if:

the waters are smelly or coloured

you're losing blood

This could mean you and your baby need urgent attention.

If your waters break before labour starts, call your midwife. Use a sanitary pad (not a tampon) so your midwife can check the colour of the waters.

If labour does not start after your waters break

It's usual to go into labour within 24 hours of the waters breaking. You'll be offered an induction if you do not because, without amniotic fluid, there's an increased risk of infection for your baby.

Until your induction, or if you choose to wait for labour to start naturally, tell your midwife immediately if:

your baby moves less than usual

there's any change in the colour or smell of any fluid coming from your vagina

You should take your temperature every 4 hours when you're awake, and tell your midwife if it's raised. A raised temperature is usually above 37.5C, but you may need to call before this - check with your midwife.

There's no evidence that having a bath or shower after your waters have broken increases your risk of infection, but having sex might.

How to cope when labour begins

At the beginning of labour, you can:

walk or move about, if you feel like it

drink fluids - you may find sports (isotonic) drinks help keep your energy levels up

have a snack, if you feel like it

try any relaxation and breathing exercises you've learned to deal with contractions as they get stronger and more painful - your birth partner can help by doing these with you

have your birth partner rub your back - this can help relieve pain

take paracetamol according to the instructions on the packet - paracetamol is safe to take in labour

have a warm bath

Find out what happens during labour and birth, and what you can do for pain relief in the early stages of labour.

Get Start4Life pregnancy and baby emails

For information and advice you can trust, sign up for weekly Start4Life pregnancy and baby emails.

Community content from HealthUnlocked

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There are several signs that labour might be starting, including: contractions or tightenings a "show", when the plug of mucus from your cervix (entrance to your womb, or uterus) comes away backache an urge to go to the toilet, which is caused by your baby's head pressing on your bowel your waters breaking The early (latent) stage of labour can take some time.

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Video showing a planned caesarean birth.

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Video showing a planned caesarean birth.

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

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

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

When should I get in the pool?

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

How can my birth partner help?

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

What will my midwife do?

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

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

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

What temperature will the birthing pool be?

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

What if I want to get out?

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

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

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

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

Will my midwife suggest I get out of the water?

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

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

What happens if my baby is born in water?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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How to labour in water or have a water birth

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Many women find having a bath or shower very comfortable in pregnancy, and this feeling of relaxation in water can continue in labour. What's not to love about it - it's warm and you're buoyant so you can move more easily into any position that suits you.

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@ Dr Sarah J. Buckley 2020 www.sarahbuckley.com
Previously published in Australia's Parents Pregnancy magazine, Autumn 1999, as "Your Hormones are your Helpers"

Imagine this. Your cat is pregnant, due to give birth around the same time as you are. You have your bags packed for hospital, and are awaiting the first signs of labour with excitement and a little nervousness.

Meanwhile your cat has been hunting for an out-of-the way place - your socks drawer or laundry basket - where she in unlikely to be disturbed. When you notice, you open the wardrobe door, but she moves again. Intrigued, you notice that your observation, even your presence, seems to disturb the whole process. And, wish as you might to get a glimpse into the mysteries of birth before it is your turn, you wake up the next morning to find her washing her four newborn kittens in the linen cupboard.

Why does birth seem so easy to our animal friends when it is so difficult for us? One obvious difference is the altered shape of the pelvis and birth outlet that is caused by our upright stance; our babies need to twist and turn to navigate these unique bends. Even our nearest cousins, the great apes, have a near-straight birth canal.

However, in every other way, human birth is like that of other mammals - those animals that suckle their young - and involves the same hormones: the body's chemical messengers. These hormones, which originate in the deepest and oldest parts of our brain, cause the physical processes of labour and birth, as well as exerting a powerful influence on our emotions and behaviour.

Researchers such as French surgeon and natural birth pioneer Michel Odent believe that if we can be more respectful of our mammalian roots, and the hormones that we share, we can have more chance of a straightforward birth ourselves.

Labour and birth involve peak levels of the hormones oxytocin, sometimes called the hormone of love, and prolactin - the mothering hormone. These two hormones are perhaps best known for their role in breastfeeding. As well as these, beta-endorphin, the body's natural pain-killer, and the fight-or-flight hormones adrenaline and noradrenaline (epinephrine and norepinephrine) play an important part in the birth process. There are many more hormonal influences on birth that are not well understood.

All mammals seek a safe place to give birth. This "nesting" instinct may be due to an increase in levels of prolactin, which is sometimes referred to as the nesting hormone. At this stage, as you may have observed with your cat, interference which the nest - or more importantly with the feeling of safety - will stall the beginning of labour.

Even after labour has started, there are certain conditions that will slow, or even stop the process. If the fight-or-flight hormones are activated by feelings of fear or danger, contractions will slow down. Our mammalian bodies are designed to give birth in the wilds, where it is an advantage to postpone labour when there is danger, and to seek safety.

Many women have had the experience of their labour stopping when they entered the unfamiliar surroundings of a hospital, and some women can be as sensitive as a cat to the presence of an observer. Giving birth away from our natural environment can cause the sorts of difficulties for humans that captive animals experience when giving birth in a zoo.

Michel Odent cautions that even hunger, which also causes the body to release fight-or-flight hormones, can stop labour from progressing. He advises women to eat - if they are hungry - in the earliest stages of labour; many hospitals, though, have a policy that prevents labouring women from eating once they are admitted.

Oxytocin is the hormone that causes the uterus to contract during labour. Levels of oxytocin gradually increase throughout labour, and are highest around the time of birth, when it contributes to the euphoria and receptiveness to her baby that a mother usually feels after an unmedicated birth. This peak, which is triggered by sensations of stretching of the birth canal as the baby is born, does not occur when an epidural is in place. Administration of an epidural has been found to interfere with bonding between ewes and their newborn lambs.

Synthetic oxytocin is often given by drip - that is, directly into the bloodstream - when labour contractions are inefficient. Oxytocin given in this way does not enter the brain, and so does not contribute to the post-birth "high", and in fact can lead to desensitisation to the mothers own oxytocin production. Nipple stimulation is sometimes used to stimulate contractions because, like breastfeeding, this causes oxytocin levels to increase.

Oxy tocin has another crucial role to play after the birth. Oxytocin causes the contractions that lead to separation of the placenta from the uterus, and its release as the "after-birth". When oxytocin levels are high, strong contractions occur that reduce the chance of bleeding, or post-partum haemorrhage.

Putting your newborn baby to your breast is the easiest way to increase oxytocin levels, but Michel Odent also emphasises the importance of privacy during the hour following birth. This gives the opportunity for uninterrupted skin-to-skin and eye-to-eye contact between mother and baby - conditions that optimise oxytocin release.

Oxytocin helps us in our emotional, as well as our physical, transition to motherhood. From the first weeks of pregnancy, oxytocin helps us to be more emotionally open and more receptive to social contact and support. As the hormone of orgasm, labour and breastfeeding, oxytocin encourages us to "forget ourselves", either through altruism - service to others - or through feelings of love.

The fight or flight hormones - also called catecholamines (pronounced cat-e-kol-a-meens), or CAs- can interfere with oxytocin release during labour and after the birth. However they do have an important role to play in the second stage of labour, which is when birth actually occurs.

Early in second stage, when the cervix is fully open but the urge to push is not yet strong, a woman can feel the need to rest for some time. This is sometimes known as the "rest and be thankful" time. After this, she may quite suddenly experience the dry mouth, dilated pupils and sudden burst of energy that are all characteristic of high levels of CAs.

T his burst of CA's gives a mother the energy to push her baby out, and Michel Odent observes that, when unmedicated, women usually want to be upright at this time. Some traditional cultures have used this fight-or-flight effect to help women having difficulty with the delivery by surprising or shouting out at this stage. It makes sense, at this point-of-no-return, for fear or danger to speed up the birth, so that a mother can gather up her newborn baby and run for safety.

CA levels drop quickly after the birth, which can make a mother may feel cold or shaky. At this stage a very warm atmosphere is essential, according to Michel Odent, to keep CA levels low and to allow oxytocin to work effectively to prevent bleeding.

Prolactin, another childbearing hormone, is most noteworthy for its effects after the birth. Prolactin is the major hormone of breast milk synthesis. Suckling by the newborn baby increases prolactin levels; early and frequent suckling from the first days makes the breast more responsive to prolactin, which in turn helps to ensure a good long-term supply of milk.

Like the other hormones, prolactin has effects on emotion and behaviour. Prolactin helps us to put our babies needs first in all situations by increasing submissiveness, anxiety and vigilance.

When prolactin is combined with oxytocin, as it is soon after birth and during breastfeeding, it encourages a relaxed and selfless devotion to the baby that contributes to a mother's satisfaction and her baby's physical and emotional health.

Beta endorphin (pronounced beet-a en-door-fin) is one of the endorphins that are released by the brain in times of stress or pain, and is a natural equivalent to painkilling drugs like pethidine.

During labour, beta-endorphin helps to relieve pain, and contributes to the "on another planet" feeling that women experience when they labour without drugs. Levels of beta-endorphin are reduced when drugs are used for pain relief.

Very high levels of beta-endorphin can slow labour by reducing oxytocin levels, which may help to "ration" the intensity of labour according to our ability to deal with it. Moderate levels of beta-endorphin help us to deal with pain in labour, as well as encouraging us to follow our instincts. As part of the hormonal cocktail after birth, beta-endorphin plays a role in bonding between mother and baby, who is also primed with endorphins from the birth process.

Beta-endorphin also switches on learning and memory, perhaps explaining why we remember our labour and birth in such amazing detail. Like oxytocin, endorphin hormones can induce euphoria and are also released during lovemaking and breastfeeding. In fact endorphins are actually present in breast milk, which explains the natural high that babies can get after a breast-feed. Beta-endorphin helps the body to release prolactin, underlining the elaborate interplay between these hormones of labour, birth and breastfeeding.

So there you are, at the door, with your bag in your hand and a strong contraction. You remember the oxytocin and endorphins, which you also carry with you, and with your next relaxed breath, you breathe out fear and tension. You've packed your new nursing bra, and you know that prolactin will come to your aid as well. As you take a last look around the house, you notice your cat. She's lying down as her kittens attach to her nipples, and as you catch her eye, she winks at you.

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Pain in Labour: Your hormones are your helpers - Dr Sarah Buckley

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@ Dr Sarah J. Buckley 2020 www.sarahbuckley.com Previously published in Australia's Parents Pregnancy magazine, Autumn 1999, as "Your Hormones are your Helpers" Imagine this. Your cat is pregnant, due to give birth around the same time as you are. You have your bags packed for hospital, and are...

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What happens for a caesarian birth

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If you are having a planned (elective) Caesarian the same things are done but in a much more leisurely manner

If it is unplanned it may all may seem overwhelming to you, with people milling about, but this is what is happening (not necessarily in this order).

The baby's heartbeat is listened to get a baseline and to ensure that it is satisfactory. This is usually done with a continuous CTG machine, which is really useful in these circumstances. If you are having a CS because of concern about the baby, listening to it will help to ascertain the degree of urgency.

The anaesthetist will be asking you about your history of having operations and anaesthetics, and about allergies. A spinal, epidural, or general anaesthetic will be advised, and an intravenous drip started in a vein in your arm, if one is not already in place.

If you have not already done so, you will be asked to sign a form of consent to the operation. Ideally this should be done with time for you to ask questions. However, if time is important, it may seem that we are hurrying you. But if we asked you to consent to anything before the need is apparent, that could be criticised. Could we do this better? But how?? Any ideas??

A blood pressure cuff will be put on your upper arm so that your blood pressure can easily be checked by a machine.

A clasp rather like a large clothes peg may be put on one of your fingers. This helps monitor the amount of oxygen in your blood

Little sticky plasters with wires attached will be put on your chest to keep a check on your heart beat.

Somebody will be taking blood from one of your veins to cross match with donated blood to make sure that compatible blood is available if needed. A test of your blood quality (a full blood count) will also be done on this specimen.

Some rather tight white elastic stockings will be put on your legs. These are to prevent any clots forming in your leg veins during the operation. In some hospitals inflatable sort of boots, rather like snow boots are used for the same purpose.

Somebody else will be putting a soft plastic tube, called a catheter, into your bladder to empty it. This is left in, and attached to a plastic bag to make sure your bladder stays empty during the operation, and for a day or so after, so that you do not need to get out of bed to go to the loo. If you would prefer it, this can be done once you are anaesthetised either by general anaesthetic or once the spinal or epidural anaesthetic is working.

A sort of bandage called a diathermy will be wrapped round your upper left leg. This is connected to apparatus which seals blood vessels during the operation, so that blood loss can be kept to a minimum.

Somebody will be asking you to remove any loose jewellery, earrings, watch, bracelets, necklaces, etc. so that they cannot become detached. Fixed jewellery, like rings will be covered by sticking plaster to avoid static electricity building up. The family diamonds and your Rolex should really have been left at home, but if you have any valuable jewellery please make sure it is given into your partner's care

Somebody else will be shaving the hair at the bottom of your bump (your pubic hair). We do not shave the hair between your legs, just the bit where the stitches will be, so that hairs do not get caught in the stitches.

You may be asked to drink some salty tasting medicine. This is sodium citrate, and it is to make your stomach juices less acid, so that if you vomit it will not be acidic.

A name band is put on your wrist, if one is not already there, so that if you do need a general anaesthetic, your name can be checked. If you are allergic to anything another wristband usually a red one will be attached with an allergy warning printed on it. Don't forget to tell us about any allergies.

All the people in theatre have to wear special sort of footwear usually clogs, or boots that have special antistatic soles to avoid static electricity building up. The clogs are noisy. We also wear clean closely woven cotton clothes, cover our hair and sometimes our mouths, to help avoid infection.

A very large and bright light will be positioned overhead to enable the surgeon to have a very good light to work under this light is quite hot.

The surgeon will probably want to do a final check on your abdomen to feel how the baby is lying, it may be necessary to examine you internally.

While all of this is happening to you, other people are getting other things ready. The person who will be passing instruments and equipment to the surgeon is setting out on trolleys everything likely to be needed, so that it is ready to hand. They count and check with another person how many instruments, swabs, stitches they have, so that during the operation they can keep track, and ensure that you don't leave theatre with more than you came in with! These two people may just seem to be chatting, but they are counting out loud to each other.

The paediatrician (baby doctor) will come in, prepare and check the resuscitation equipment, in case your baby needs help after it is born.

We use suction equipment during the operation and check it before we start. This makes a hissing noise.

There is a lot to be done, if it has all to be done quickly, it must seem like everyone is scurrying around in a chaotic fashion. But it is organised chaos, and very necessary. We do check and cross check, that it is all done before we start.

In addition to all this, at least four people will be "scrubbing up" and putting on sterile clothes. They will be:

1. The person in charge of the instruments as mentioned previously, she or he will have scrubbed up first, and everybody else has to avoid touching this person as they move around.

2. The surgeon

3. Another doctor or midwife to assist the surgeon

4. The midwife who will take the baby to the paediatician, and assist with the resuscitation of the baby if necessary.

Other people who may be in theatre

If there is serious concern about the baby there may be a specialist baby nurse present as well.

A nurse or midwife who is "running" This is someone who is fetching and carrying and generally assisting, but who is not "scrubbed up" They will check the swabs used and the instruments used with the scrubbed, instrument person.

An operating department assistant. This is a person with special training whose role is to assist the anaesthetist.

Your own midwife to give you support, though she may have been asked to scrub to assist, or to take the baby.

Your partner or other relative or friend of your choice, who will be asked to wear the special theatre clothes.

Even though birth by Caesarian Section is not without risks and is marginally not as safe as a normal birth, everything that is being done to and for you is being done to make the operative birth of your baby as safe for you and your baby as possible.

If you are having an epidural or spinal anaesthetic the anaesthetist will check very carefully that you will not feel any pain during the operation, though it will be explained that you will feel the movements of the baby being delivered through the incision in your abdomen. Many anaesthetists check the effectiveness of the numbness of your abdomen by rubbing a block of ice over your abdomen and possibly your breasts. Research has shown that the ice is a better method of ascertaining a complete numbness that using a pinprick. The anaesthetist will explain exactly what s/he is doing and that if you have chosen an epidural or spinal anaesthetic it is very occasionally necessary to give you a general anaesthetic i.e. put you to sleep. Please do not hesitate to ask the anaesthetist or surgeon any questions you wish.
Back to Mary Cronk's homepage

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If you are having a planned (elective) Caesarian the same things are done but in a much more leisurely manner If it is unplanned it may all may seem overwhelming to you, with people milling about, but this is what is happening (not necessarily in this order).

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Where are my pelvic floor muscles?

Your pelvic floor muscles surround and support all the organs in your pelvis - your womb, bowels and bladder.

You can find out where the pelvic floor muscles are and how you control them next time you go to the toilet. As you wee, try to stop the flow briefly. The muscles you use to do this are your pelvic floor muscles.

Don't do this more than once, though - it's not good for your bladder to stop mid-wee and doing it regularly may lead to a urinary tract infection.

During your pregnancy, your pelvic floor muscles will loosen due to hormonal changes in your body. This loosening, along with your growing baby pressing on your bladder, may cause you to leak urine when you cough, laugh, sneeze or exercise.

Doing pelvic floor exercises will strengthen these muscles and help you control any accidents. It will also help you ease your baby out and recover faster after the birth.

How do I exercise my pelvic floor muscles?

Once you've found your pelvic floor muscles, try stopping an imaginary wee rather than a real one. Once you can locate them like this, you can exercise them any time you like by tightening and lifting them.

To tighten and lift your pelvic floor muscles, imagine doing the following at the same time:

Squeezing your bottom as if stopping a poo

Squeezing to stop the flow of wee

Squeezing as though you're gripping a tampon in your vagina.

You can do pelvic floor exercises anywhere you like. Nobody will know what you're doing - as long as you don't raise your eyebrows each time you squeeze!

You can exercise on the bus, while you're on the phone or waiting in the supermarket queue.

Practise at home!

Practise these exercises in front of a mirror. Then you'll know you can do them without making faces before you try them on a crowded bus or at work!

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Your pelvic floor muscles surround and support all the organs in your pelvis - your womb, bowels and bladder. You can find out where the pelvic floor muscles are and how you control them next time you go to the toilet. As you wee, try to stop the flow briefly.

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Considerations for a caesarean birth plan

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Considerations for a caesarean birth plan

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Great ideas from Babycentre

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Whether it's your partner, daughter or friend due to give birth, it's an honour to be asked to be a birth partner. Yet this exciting role can also be daunting. Here we discuss some top tips to help you get ready.

You'll find a whole number of ways you can help support the mum-to-be during labour (NHS Choices, 2017a). One place to start is by talking to them in advance about their expectations of you - ask them how they'd like you to support them. This will help you both feel more prepared ahead of the birth and confident in your role as birth partner (NHS Choices, 2017b).

Watch this video for tips on how to support your partner during labour.

1. Be prepared

Birth partners should be prepared and ready. The weeks around their due date are not a good time to book an impromptu holiday or be in a meeting with your mobile phone switched off.

Talk through their birth plan (if they have one) with the mum-to-be well in advance. Attending birth classes like an NCT course together can help you learn about what to expect in labour (Which? Birth Choice, 2018). Classes will also help you write a birth plan if you want one (Which? Birth Choice, 2018).

Ask your partner if there are any specific ways they would like you to support them during labour and the birth. Also ask about any no-go areas. And know your limits too - if there are bits of the birth you prefer not to get hands on with, make it clear beforehand. For example, let her know if you don't want to help cut the baby's umbilical cord.

If you're planning to use any new kit during labour like a TENS machine, make sure you test it out ahead of time and know how to use it.

2. Be there and know what she wants

The number one thing you can do for a woman in labour is be there as continuous support for them and help them with whatever they need at the time. Research has shown that having a familiar birth partner present throughout labour can help improve the birth experience (Bohren et al, 2017).

Whether that's simply being there to hold her hand, or offering moral support and bringing some positive energy to the room (NHS, 2017b). Try to talk about what emotional, physical and practical support she would like too. Help her write down a birth plan or talk through it if she would like to. That way, you know her preferred birth choices like the back of your hand.

3. Provide company

During the early stages of labour you can help keep her company, make sure she is comfortable and help pass the time together.

You might be able to go for a walk together in the early stages of labour, watch television, listen to music or read together.

You can assist with whatever helps the mum-to-be feel comfy. She might like you to help her to bath, you could fetch her some relaxing creature comforts, or give her a hand to keep moving.

You'll also need a break. Make sure you bring some snacks for you too and wear comfy clothes to keep yourself in top form (Northern Lincolnshire and Goole NHS, 2015).

4. Give her practical support

You can help in lots of practical ways. You could drive the mum-to-be to the hospital, carrying her hospital bag and helping her check into the birthing suite or hospital (NHS, 2017b).

When you get there, you could do things like helping her to move around the room and change positions. She might love you to give her a back rub or get her a cup of tea.

If she is planning a home birth you can help set up everything she needs at home, whether that's a birthing pool or somewhere comfy for the mum-to-be. On the day you could offer to get the mum-to-be a hot drink and make phone calls to keep family updated.

The key here is to discuss and plan in advance what practical support she would like you to provide.

5. Provide emotional support

As the mum-to-be's labour progresses and contractions get stronger you can be her rock, comforting and reassuring her. Simple gestures like holding or squeezing her hand and giving positive words of encouragement can really help.

6. Support her physically and take care of yourself

You can encourage the mum-to-be to keep active during labour and help her move about or change positions so she feels more comfortable (NHS, 2017b). You could also offer to massage her back and shoulders, wipe her face with a cold flannel, or simply give her a reassuring hug. You might also find you need to back off a bit if she needs space. Ask what she'd prefer.

To continue to support the mum-to-be well during labour, you also need to be on top form. You might be supporting and providing comfort to her for a long time. You may even find you haven't slept all night and are extremely tired.

So take time out if you need it - whether that's going for a quick toilet break, getting a hot drink or stepping out to make a phone call. Make sure you bring snacks and wear comfy clothes (Northern Lincolnshire and Goole NHS, 2015).

7. Listen to her

Try to really listen to what she needs on the day. It can be easier said than done but you will need to be intuitive and try and understand what she needs and when. Especially if she is in too much pain to express it well herself.

Be aware that her needs might change as her labour progresses. At times during labour, the mum-to-be might like emotional and physical support. Yet there might be other times when she would like to be left alone to help her focus.

8. Be confident, encourage and motivate

If you are upbeat and confident in a woman's ability to give birth, this will help encourage and support her.

Words are powerful. You can help your partner stay motivated during labour by offering words of encouragement. Tell her how much you love her, how well she is doing. Also respect her wishes if she asks you to be quiet.

Encourage her to use any relaxation and breathing techniques you have learnt, perhaps by doing them with her. She might not be able to see what is happening as the baby is being born. So help to motivate her by telling her what is happening and when you can see the baby's head.

9. Be an advocate

You might need to express the mum-to-be's needs to the midwife or doctor (NHS, 2017b). So help to explain to the health professional what she would like. You might also need to explain to her any new information from the health professionals.

Support the mum-to-be's decisions, even if they're different from what's in her birth plan. She might want to choose a different type of pain relief, for example.

10. Be flexible

Be prepared to be flexible. No two labours are the same and, although you can prepare, you will need to adapt to whatever is working or not working during labour. It's possible that everything will go to plan but you might also find that an urgent medical situation arises and alters the course of the labour.

If this happens, tell the mum-to-be what's happening if you can and continue to encourage and reassure her. This will help her feel more in control of the situation.

You might be waiting a long time for her labour to progress, or you may have to make quick decisions based on medical advice and her best interests. Be prepared to be flexible on the day and go with the flow.

Give yourself a pat on the back too

Being a birth partner can be an incredibly rewarding experience. Yet it can also be nerve wracking and emotionally draining.

As well as congratulating the mum-to-be on their new arrival, don't forget to take some time out for yourself afterwards and talk to a friend about it. Make sure you give yourself some recognition for the part you have played in the baby's birth too.

Further information

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

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

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

Find out more about NCT Doulas and how they can during labour. NCT Doulas provide women, and their partners, with skilled physical and emotional assistance during labour. They have up-to-date knowledge and information about labour and birth and help provide encouragement to woman. This helps enable them to have the type of labour and birth they would like. NCT Doulas are qualified professionals who have completed a professional Doula UK course, developed by NCT in partnership with the University of Worcester.

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Whether it's your partner, daughter or friend due to give birth, it's an honour to be asked to be a birth partner. Yet this exciting role can also be daunting. Here we discuss some top tips to help you get ready. You'll find a whole number of ways you can help support the mum-to-be during labour (NHS Choices, 2017a).

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Hi, everyone. In this video, we're going to talk about the evidence on using relaxation for pain relief during labor.

Hi. My name's Rebecca Dekker, and I'm a nurse with my Ph.D. and the founder of EvidenceBasedBirth.com. In today's video, we're going to continue our pain management series by talking about the effects of relaxation techniques on pain management during labor. The goal of using relaxation techniques is to elicit the body's natural relaxation response, which consists of slower breathing, lower blood pressure and a general sense of wellbeing and calm.

The relaxation response

The relaxation response was actually popularized by a book written with that name and published in 1975 by Herbert Benson, a Harvard physician, and Miriam Klipper. This book was a simple secularized version of transcendental meditation techniques, which come from India. It was written for people in the western world so that they could learn how to activate their parasympathetic nervous system. The parasympathetic nervous system is the part of your peripheral nervous system that causes humans to relax. It counters the fight-or-flight or adrenaline part of the peripheral nervous system. That counterpart is the sympathetic nervous system. So with the relaxation response, you're trying to get that parasympathetic nervous system to kick in. When that happens, you move from a state of arousal or fight or flight to one of relaxation, calm, and feeling at peace. This has a variety of physiologic benefits, including lowering your blood pressure, heart rate, and breathing pattern.

Relaxation techniques are generally considered safe around the world. However, there have been a few case reports of people who had the opposite intended effect, where they felt more anxious when they tried to get the relaxation response.

Relaxation overlaps a lot with many of the other techniques we've covered in this pain management series. That's because in many studies there are many different comfort measures that can elicit the relaxation response and that are often used in combination with each other. For example, music, aromatherapy, massage, getting in a warm tub of water, or different breathing techniques, can all work together to create a sense of relaxation. When we combine these types of comfort measures together it's really difficult to tell which part of the combination is creating the results.

Relaxation techniques

Some of the relaxation techniques that are used in research studies with laboring people, that we haven't covered yet, include progressive muscle relaxation, guided imagery, and visualization. Then we recently just talked about psychoprophylaxis in our video all about breathing techniques. The term psychoprophylaxis refers to combining relaxation methods with breathing techniques, and it was first introduced to the world by Lamaze in 1960.

With guided imagery and visualization, the person recalls or imagines a pleasant, enjoyable and relaxing experience. This kind of imagery can be guided or unguided. For example, with guided imagery, you may listen to an audio file or a script of someone reading to you, to help bring you to that pleasant place where you can relax and enjoy the visualization. Unguided imagery may involve doing something like scanning your body for sensations of pain and replacing those sensations in your mind with feelings of comfort, heat or cold. MRI studies have found that guided imagery changes the way that the brain perceives pain.

Progressive muscle relaxation was first described by Edmund Jacobson in 1938. With progressive muscle relaxation, people are guided to successively tense and then release different muscles in their body, often starting from the toes and working their way up to the head to achieve a sense of relaxation.

So how might relaxation for pain relief work during labor?

Researchers think that relaxation for pain relief may work by interrupting the transmission of pain signals to the brain, helping you focus on something positive, so giving you a positive source of distraction, stimulating the release of endorphins (your body's natural pain-relieving hormones), and reframing your thoughts to think of labor sensations as positive, productive and manageable.

It's also thought that the more you tense up, the worse pain can feel. One example I give my clients in my childbirth classes is, for someone like me who was raised in the south, the winters up north felt very painful to me. I would tense up when I would go outside even if I was all decked out in a coat and gloves and a hat and scarf. But tensing my muscles actually caused pain. So you can only imagine that during labor, if you are tensing up your body, then labor may feel more painful. Working on relaxing your body decreases what we call the fear-tension-pain cycle, where fear and tension feed into and make pain feel worse.

Now, the theory through which all this happens is called the central nervous system control (CNSC) mechanism of pain relief. This means that entering into a state of relaxation may create mental processes that make labor feel less unpleasant. We've covered a lot of these CNSC mechanisms in our pain management series, some examples include hypnosis, music, aromatherapy, breathing, and continuous labor support from a doula.

But what's the evidence specifically on using relaxation for pain relief during labor?

Smith et al. (2018) Cochrane review and meta-analysis

Well, in 2018, Smith et al. published a Cochrane review and meta-analysis looking at 10 randomized, controlled trials that compared relaxation methods with standard care during labor. Eight of these studies were able to be combined into what we call a meta-analysis, where they pool or combine all the data into one larger study, with a total of nearly 1,400 people.

These are the types of relaxation methods that were studied: deep breathing and relaxation were studied in one trial; relaxation, music and guided imagery were in one study; relaxation and music were combined in another study; stretching, relaxation, massage and breathing were combined in another study; progressive muscle relaxation, breathing techniques, massage and position changes were in another study; then three studies looked at psychoprophylaxis, or childbirth education where participants were taught how to respond to contractions with relaxation and breathing techniques.

Relaxation as a comfort measure in early labor

The researchers were able to look at the effects of the relaxation for pain relief during early labor in only one small study from Turkey with 40 participants. This study found that during early labor, the relaxation intervention decreased the pain score by about 1.25 points. This was the study where they combined progressive muscle relaxation, breathing techniques, position changes, additional nursing support, and massage, compared to usual care. This was the only study in the entire Cochrane review that reported on women's satisfaction with their pain relief during labor, and they found that the people assigned to the relaxation combo intervention did have higher satisfaction levels with their pain relief.

Relaxation as a comfort measure in active labor

Four trials with 271 participants reported on the effects of relaxation on pain intensity in active labor, so further along in the labor process. They found mixed results in the studies, and overall there was no difference in pain intensity during active labor when you compared the groups who had the relaxation intervention with those who did not.

Only one of the studies reported on rates of epidural use in the groups. This was a large study from Sweden with 977 participants. In this study, women in the intervention group had a psychoprophylactic childbirth education intervention where they were instructed on how to use breathing, muscle relaxation, and massage. They compared that to standard childbirth education that did not include those techniques, and they did not find any differences in epidural rates between the two groups.

Three of the studies that looked at maternal satisfaction with their overall childbirth experience did not find a difference between groups, and none of the researchers looked to see if women felt a sense of control during the labor process.

Levett et al. (2016) RCT

There's one more randomized trial that I wanted to talk about that was not included in the Cochrane review, this is the study by Levitt et al. published in 2016. We've talked about it in several of our other videos, including the videos on acupressure, childbirth education, and breathing techniques. In this study, which took place in two hospitals in Australia, 176 low-risk, first-time mothers were randomly assigned to either a complete childbirth class or standard care alone, which consisted of a typical childbirth class. The complete childbirth class was a two-day class based on techniques from the She Births class in Australia. This two-day course included four guided visualizations that were rehearsed in the class and also given to participants on a CD to practice the visualization at home. In addition to the visualization, they also incorporated other complementary medicine techniques including acupressure, breathing techniques, massage, yoga and facilitated partner support.

The researchers in this study were primarily interested in the rate of epidural use, and they did find that women who were randomly assigned to the complete childbirth class had a significantly lower epidural rate compared to those who took the typical childbirth class. In addition, they had lower rates of labor intervention and a shorter labor on average. Unfortunately, they did not report maternal satisfaction with the birth experience. When the researchers asked women from the complete childbirth class which of the techniques they had actually used during labor, the breathing techniques were used most often, by 60% of the women. Visualization was also used by 56% of women from the complete childbirth class group.

This study provides evidence that childbirth education that includes complementary medicine techniques such as visualization, breathing, massage, and yoga, is an effective and viable way of managing pain in low-risk, first-time mothers.

Relaxation for pain relief outside of childbirth

Another meta-analysis was published in 2001 about relaxation for pain relief. But in this study, these researchers were not looking at pregnant women, they were actually looking at a cancer population. They looked at 15 studies that had been published up until that point, and they found that relaxation training, which was progressive muscle relaxation and guided imagery, was effective for decreasing nausea and pain from medical treatment. It also had a significant beneficial effect on blood pressure, heart rate, and led to lower rates of depression, anxiety, less muscle tension, and an improved mood. They concluded that relaxation for pain relief is inexpensive, has no known side effects, is easy to learn, and is usually welcomed by the patient. They also state that relaxation for pain relief may give patients a sense of control over their treatment instead of common feelings of helplessness.

Conclusion

In summary, there is a lack of high-quality research evidence on relaxation for pain relief during labor. Due to the wide variation and the different ways that relaxation is implemented in these studies, we don't know which relaxation techniques work best. One small trial from the Cochrane review found that a relaxation intervention that includes progressive muscle relaxation, breathing techniques, position changes, additional nursing support, and massage - in combination - was linked to lower pain scores in early labor and a greater maternal satisfaction with pain relief.

Researchers have not found any clear benefit from relaxation interventions on pain scores during active labor. The study from Australia, however, found that a complete childbirth course that included six different complementary medicine techniques, including guided imagery for relaxation, was linked with lower epidural rates and lower rates of other interventions.

One other resource that I'd like to point you to is Penny Simkin's video all about the three Rs: Relaxation, Rhythm, and Ritual.

Finally, I just wanted to say again that relaxation is not only used by many people during childbirth but also for many reasons outside of the realm of childbirth.

The bottom line is that relaxation techniques are safe to use and may have benefits such as reducing pain during early labor and reducing rates of other interventions such as epidurals. That's it for this topic. If you enjoyed this video, please hit subscribe so that you can get notifications when our other YouTube videos come out. Also, I'd like to encourage you to watch some of the other videos in our pain management series. We cover everything from epidurals and nitrous oxide (laughing gas) to hypnosis and massage. Thanks, everyone, for watching. Bye.

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Relaxation for Pain Relief During Labor - Evidence Based Birth®

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Hi, everyone. In this video, we're going to talk about the evidence on using relaxation for pain relief during labor. Hi. My name's Rebecca Dekker, and I'm a nurse with my Ph.D. and the founder of EvidenceBasedBirth.com. In today's video, we're going to continue our pain management series by talking about the effects of relaxation techniques on pain management during labor.

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Royal College of Obstetricians & Gynaecologists

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This information is for you if you think that, or have been told that, your waters have broken early but you have not gone into labour.

It may also be helpful if you are a partner, friend or relative of someone who is in this situation.

This applies to you if your waters may have broken between 24 and 37 completed weeks of pregnancy.

If your waters break before 24 weeks, you should have a discussion with your healthcare professional about your individual circumstances.

See a full glossary of medical terms.

The information here aims to help you better understand your health and your options for treatment and care. Your healthcare team is there to support you in making decisions that are right for you. They can help by discussing your situation with you and answering your questions.

This information covers:

What Preterm Prelabour Rupture of Membranes (PPROM) is

What you should do if you have PPROM

What happens at hospital and if PPROM is diagnosed

What PPROM could mean for you and your baby

Treatment options

Information about giving birth

What PPROM means for future pregnancies

Further information and support available

Key points

Preterm prelabour rupture of membranes (PPROM) is when your waters break before 37 completed weeks of pregnancy but you haven't gone into labour yet.

If this happens, you have a higher chance of giving birth prematurely and there is an increased chance that both you and your baby may develop an infection that can make you both unwell.

You will be offered a course of antibiotics to reduce the risk of an infection developing and to help the pregnancy to continue.

If you are well with no signs of infection and your baby is growing well in your uterus (womb), then it may be better to allow your pregnancy to continue until 37 weeks. You will be monitored very closely for any signs of infection by your healthcare team, and your individual circumstances and preferences will be taken into account.

If you or your baby show any signs of infection or develop other complications, you may need to give birth to your baby straight away.

What is preterm prelabour rupture of membranes (PPROM)?

Your baby is surrounded by amniotic fluid or 'waters' contained within a membrane bag (the amniotic sac) inside your uterus.

When the waters break, it is also known as rupture of the membranes.

Normally your waters break shortly before or during labour.

If your waters break before labour at less than 37 weeks of pregnancy, this is known as preterm prelabour rupture of membranes (PPROM).

This can happen in up to 3 out of every 100 (3%) pregnant women.

PPROM is associated with 3-4 out of every 10 preterm births.

The reason why PPROM happens is not always known, but may be because of infections, placental problems or other causes.

Diagram showing a baby in the womb, marking the placenta, umbilical cord, amniotic sac and amniotic fluid:

How will I know if my waters have broken?

You may notice a 'gush' of fluid or you may feel damp. The amount of fluid you lose may vary from a trickle to a gush.

What should I do?

If you think that you are leaking fluid from the vagina, wear a pad not a tampon and note the colour and amount of the fluid.

Leaking urine is common while you're pregnant, but if you think your waters may have broken, you should contact your healthcare professional and go to the hospital for a check-up straight away.

What happens at the hospital?

You will have a check-up that should include:

a discussion with your healthcare professional about what has happened, including details about the fluid loss, how you are feeling, how your pregnancy has been so far and whether you have any risk factors for PPROM or preterm birth (for example, if this has happened in previous pregnancies it is more likely to happen again)

a check of your general health, including an examination and a check of your temperature, pulse and blood pressure

a check of your baby's heartbeat.

How is PPROM diagnosed?

PPROM is best diagnosed by a vaginal examination. With your consent, your healthcare professional will use a sterile speculum (an instrument used to separate the walls of the vagina) to look at your cervix and see whether the leaking fluid is amniotic fluid.

A swab test of the fluid may help to decide whether your waters have broken, if it is still unclear after the speculum examination.

An ultrasound scan to estimate the amount of fluid around your baby is sometimes helpful.

What happens next?

If your waters have broken, you will usually be advised to stay in hospital for a few days, although in some situations this may be for longer.

You and your baby will be closely monitored for signs of infection.

This will include having your temperature, blood pressure and pulse taken regularly, together with blood tests to check for infection.

Your baby's heart rate will also be monitored regularly.

If your waters have not broken, you should be able to go home.

If only a very small amount of amniotic fluid is leaking, it is not always easy to see on examination and it can be difficult to confirm whether your waters have broken.

If you continue to leak fluid at home, you should return to the hospital for a further check-up.

What could PPROM mean for me and for my baby?

Infection

The membranes form a protective barrier around the baby, and after these have broken, there is a risk of infection getting into your uterus ( chorioamnionitis). If you have an infection, this can cause you to go into labour early or cause you or your baby to develop sepsis.

The symptoms of infection include a raised temperature, an unusual vaginal discharge with an unpleasant smell, a fast pulse rate and pain in your lower abdomen. Your baby's heart rate may also be faster than normal.

If there are signs that you have an infection, your baby may need to be born straight away to try to prevent both you and your baby becoming more unwell.

Preterm birth

About 50% of women with PPROM will go into labour within the first week after their waters break. The further along you are in your pregnancy the more likely you are to go into labour within 1 week of your waters breaking.

Problems of prematurity

Babies born prematurely have an increased risk of health problems, particularly with breathing, feeding and infection, and may need admission to a neonatal unit. The earlier your baby is born, the more likely that this will be the case.

If your waters have broken early, your healthcare professional will discuss with you the possible outcomes for your baby, depending on how many weeks pregnant you are when this happens and on your individual circumstances.

Other complications

Cord prolapse, when the umbilical cord falls through your cervix into the vagina: this is an emergency complication and can be life-threatening for your baby, but it is uncommon.

Pulmonary hypoplasia, when your baby's lungs fail to develop normally because of a lack of fluid around them: this is more common if your waters break very early on in pregnancy (less than 24 weeks) when your baby's lungs are still developing.

Placental abruption, when your placenta separates prematurely from your uterus: this can cause heavy bleeding and can be dangerous for both you and your baby.

If you experience PPROM, sometimes your baby may not survive. The risk of this happening is greater if your waters break very early, if the baby is born very prematurely or, in some cases, following infection or cord prolapse.

Are there any treatments for PPROM?

It is not possible to replace the fluid or repair the hole in the membranes around your baby. You may carry on leaking fluid for the rest of your pregnancy as amniotic fluid continues to be made.

However, treatment may be offered to reduce the risk to your baby. This could include:

a course of antibiotic tablets to reduce the risk of an infection getting into the uterus and affecting both you and your baby; antibiotics can also help to delay you going into labour

a course of steroid injections (corticosteroids) to help with your baby's development and to reduce the chance of problems caused by being born preterm; see the RCOG patient information Corticosteroids in pregnancy to reduce complications from being born prematurely

magnesium sulfate, a medication that may be offered to you if your baby is at risk of being born very prematurely; this can reduce the risk of them developing cerebral palsy

intravenous antibiotics (if you are in preterm labour) to reduce the risk of early-onset group B Streptococcus (GBS) infection; see the RCOG patient information Group B Streptococcus (GBS) in pregnancy and newborn babies.

Do I need to stay in hospital?

You will usually be advised to stay in hospital for a few days after your waters break, to monitor both your and your baby's wellbeing. Your healthcare professional will discuss with you the option of going home after this time, if you are well and not considered to be at higher risk for giving birth early.

When should I seek help if I go home?

Before going home from hospital, your healthcare professional will give you information on symptoms to look out for. Contact your healthcare professional and return to the hospital immediately if you experience any of the following:

raised temperature

flu-like symptoms (feeling hot and shivery)

vaginal bleeding

if the leaking fluid becomes greenish or smelly

contractions or cramping pain

abdominal pain or back pain

if you are worried that the baby is not moving as normal.

What follow-up should I have?

You should have regular check-ups with your healthcare professional (usually one or two times per week).

During these check-ups, your baby's heart rate will be monitored, your temperature, pulse and blood pressure will be checked and you will have blood tests looking for signs of infection.

Your obstetrician will work with you to make an ongoing plan for your pregnancy.

Experiencing PPROM can be a very stressful time for both you and your family.

You should be offered emotional support during your pregnancy and after your baby is born.

If you are worried about how you are feeling, do seek help from your healthcare professional and support groups (see links below).

When is the right time to give birth?

If you and your baby are both well with no signs of infection then you may be advised to wait until 37 weeks to give birth. This is because carrying on with the pregnancy reduces the risk to your baby that are related to being born preterm.

If you are known to carry the GBS bacteria, then you may be advised to give birth from 34 weeks because of the risk of GBS infection in your baby. See the RCOG patient information Group B Streptococcus (GBS) in pregnancy and newborn babies.

Your healthcare professional should discuss the timing of birth with you depending on your individual circumstances and preferences. You will have the opportunity to ask any questions you have about your pregnancy and about preparing for birth.

Will I be able to have a vaginal birth after PPROM?

It is often possible to have a vaginal birth after PPROM but this will depend on when you go into labour, the position your baby is lying in in your uterus, and your own individual circumstances and choices.

Your healthcare professional will discuss this with you.

How will this affect any future pregnancy?

Having PPROM or giving birth prematurely means that you are at an increased risk of having a preterm birth in any future pregnancies.

You will be advised to be under the care of a specialist team who will discuss with you a plan for your pregnancy depending on your individual situation.

About intimate examinations

The nature of gynaecological and obstetric care means that intimate examinations are often necessary.

We understand that for some people, particularly those who may have anxiety or who have experienced trauma, physical abuse or sexual abuse, such examinations can be very difficult.

If you feel uncomfortable, anxious or distressed at any time before, during or after an examination, please let your healthcare professional know.

If you find this difficult to talk about, you may communicate your feelings in writing.

Your healthcare professionals are there to help and they can offer alternative options and support for you.

Remember that you can always ask them to stop at any time and that you are entitled to ask for a chaperone to be present. You can also bring a friend or relative if you wish.

Further information

Little Heartbeats: www.little-heartbeats.org.uk

Group B Strep Support (GBSS): https://gbss.org.uk

SANDS: www.sands.org.uk

The UK Sepsis Trust: https://sepsistrust.org

The Birth Trauma Association: www.birthtraumaassociation.org.uk

NICE guideline NG25, Preterm Labour and Birth: www.nice.org.uk/guidance/ng25

RCOG Green-top Guideline No. 73, Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation

RCOG patient information, Umbilical cord prolapse in late pregnancy

A full list of useful organisations is available on the RCOG website at www.rcog.org.uk/en/patients/other-sources-of-help

Shared Decision Making

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

Ask 3 Questions

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

1. What are my options?

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

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

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

This information has been developed by the RCOG Patient Information Committee. It is based on the RCOG Green-top Guideline No. 73, Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24⁺⁰ Weeks of Gestation, published in June 2019. The guideline contains a full list of the sources of evidence we have used.

This information has been reviewed before publication by members of the RCOG Women's Network and the RCOG Women's Voices Involvement Panel and by women attending clinics across the UK.

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This information is for you if you think that, or have been told that, your waters have broken early but you have not gone into labour. This applies to you if your waters may have broken between 24 and 37 completed weeks of pregnancy.

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NICE (National institute for health and care excellence) guidelines 

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NICE (National institute for health and care excellence) guidelines 

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Intrapartum care for healthy women and babies

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This guideline has been updated and replaced by the NICE guideline on intrapartum care

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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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Why and how can you help prevent.

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Most women will sustain some damage to their perineum during birth ( AIHW 2018). Around 50% will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). Occasionally (1% of non-instrumental vaginal births) significant tearing occurs that extends into the anal sphincter (3rd / 4th degree). You can find out more about types/grading of perineal trauma here. This post will discuss 'protecting the perineum' and was initially based on a literature review. You can find the full literature review and reference list in my thesis. I have updated the post regularly since then and have added new references in the text.

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

Before I get off my soapbox and share the research evidence...

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

Before birth

Fixed factors

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

a big baby

first vaginal birth

high weight gain in pregnancy

higher socioeconomic circumstances

older and younger maternal age

ethnicity (Caucasian and Asian)

short perineal body

nutritional status

abnormal collegan synthesis

Preparing the perineum for birth

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

A number of guidelines recommend that women should be encouraged to massage their perineums during pregnancy to reduce the chance of tearing. The reference cited to support this recommendation is a Cochrane Review. However, the review did not conclude that massage reduced the chance of tearing. It found that women having their first baby who did perineal massage were less likely to have an episiotomy - not a tear. This suggests that care providers act differently in these cases - and needs further investigation. Perhaps perineal massage helps women to fit unnecessary birthing timeframes prescribed by hospitals, therefore avoid being cut?

There is a rather scary device called an Epi-No designed to use during pregnancy to stretch the perineum. A large RCT found that "antenatal use of the Epi-No device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma." Personally I worry about potential long term effects of repeatedly stretching the perineum to the size of a babies head. Although a woman may give birth a number of times during her life, she will usually have more than a day between each baby's head stretching her vagina. It is also a reflection of our technocratic culture that a 'device' is considered to be necessary in order to prepare for childbirth.

During birth

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

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

position of baby - larger diameter of head presenting

midline episiotomy (see below)

instrumental birth - particularly forceps

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

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

shoulder dystocia

There are two main principles involved in reducing the chance of tearing:

1. A slow birth of the baby through the vagina - allowing time for the tissues to respond and stretch

2. Capacity for stretch and 'give' in the tissues

Positions

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

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

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

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

Directed pushing

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

Warm water

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

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

'Hands on' techniques

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

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

Perineal massage

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

Episiotomy

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

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

Clinical guidelines include indications for episiotomy without citing research to support those statements. For example, NICE guidelines state that an episiotomy should only be carried out if needed for an instrumental birth, or severe fetal distress. This was the standard when I trained and resulted in very few episiotomies. However, QH guidelines have recently added in additional indicators including 'soft tissue dystocia'. The citation for this statement is another guideline ( RANZOG) - and that guidelines includes no supporting evidence for the statement. 'Soft tissues dystocia' refers to a perineum not stretching 'quick' enough ie. lack of patience. In practice, care providers are cutting women if they think they may tear or if the birth is not quick enough - believing these are appropriate indications.

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

Even if episiotomy does reduces the chance of severe tearing (which we don't have the evidence for) - having an episiotomy during a non-instrumental vaginal birth would be trading a 1% chance of significant tearing with 100% chance of perineal damage via a cut.

After birth

Suturing

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

In summary

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

Further resources

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Updated: September 2019 Artwork by Dana Leggett: http://bit.ly/birthart Most women will sustain some damage to their perineum during birth (AIHW 2018). Around 50% will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). Occasionally (1% of non-instrumental vaginal births) significant tearing occurs that extends into the anal sphincter (3rd...

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Angela Horn's
Home Birth Reference Page

Your browser does not appear to support frames. No problem - please go to the non-frames version of the Home Birth Reference Page.

The non-framed pages contain the same information as the framed pages; all you will miss is the navigation bar.

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Angela Horn's Home Birth Reference Page Your browser does not appear to support frames. No problem - please go to the non-frames version of the Home Birth Reference Page. The non-framed pages contain the same information as the framed pages; all you will miss is the navigation bar.

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Evidence for positions during second stage of labour 

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Evidence for positions during second stage of labour 

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Important research about best place to have your baby

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Birthplace in England Research Programme | SHEER | NPEU

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Birthplace is a multidisciplinary programme of research addressing questions relating to the provision, safety and costs of different settings for birth in the NHS. The programme included the Birthplace national prospective cohort study, which compared perinatal and maternal outcomes by planned place of birth; a linked cost-effectiveness study; a descriptive study of the configuration of maternity care in England; and a set of qualitative organisational case studies.

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Always wise to discuss options with your midwife as types of pain relief varies between hospitals.

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Your pain relief options

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

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

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

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

Self-help in labour

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

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

learn how to relax, stay calm and breathe deeply

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

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

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

have a bath

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

Gas and air (Entonox) for labour

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

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

Side effects

there are no harmful side effects for you or the baby

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

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

Pethidine injections in labour

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

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

Side effects

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

it can make you feel woozy, sick and forgetful

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

these medicines can interfere with the baby's first feed

Epidural

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

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

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

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

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

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

How does an epidural work?

To have an epidural:

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

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

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

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

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

Side effects of epidurals in labour

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

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

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

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

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

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

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

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

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

Remifentanil

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

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

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

Side effects

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

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

Using water in labour (water birth)

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

TENS machines

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

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

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

How TENS machines work

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

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

Side effects of TENS machines

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

Alternative methods of labour pain relief

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

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

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

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Labour can be painful - it can help to learn about all the ways you can relieve the pain. It's also helpful for whoever is going to be with you during your labour to know about the different options, as well as how they can support you.

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Great video to see how you can change a hospital room to increase oxytocin levels and to encourage upright birth positions.

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What is the history of parent-infant separation after birth?

Separation of human parents and newborns is unique to the 20th and 21st centuries and is a complete break from natural human history. In the past, infant survival depended upon close and virtually continuous contact between a baby and its birth parent.

The practice of routinely separating parents and newborns started in the early 1900s, when birth began to move from homes to hospitals. At the time, most birthing people received general anesthesia (medications that induce loss of consciousness) during the pushing phase. This made birthing parents and their babies incapable of interaction after birth. Because mothers could not care for their babies, hospitals created central nurseries to care for newborns, and infants were typically separated from their parents for 24 to 48 hours after birth ( Anderson et al. 2004 ).

When did things begin to change?

Most people who give birth by Cesarean today receive regional anesthesia (an epidural, spinal, or combined spinal-epidural) instead of general anesthesia, so these birthing parents, too, are usually alert after giving birth.

Interestingly, when researchers studied human birthing parent-newborn contact in the 1900s and early 2000s, keeping birthing parents and babies together was considered the "experimental" intervention. In contrast, when researchers studied other non-human mammals, keeping mothers and babies together was always the control (or normal) condition, while separating newborns from their mothers was considered "experimental" ( Moore et al. 2016).

Kangaroo care

Kangaroo care (https://cle.clinic/3Rp7rSy) (also known as Kangaroo Mother Care or KMC) is the practice of keeping a medically fragile baby skin-to-skin with its birthing parent. Kangaroo care was developed in the late 1970s by Colombian pediatricians and neonatologists Edgar Rey Sanabria and Héctor Martínez Gómez ( Abadía-Barrero 2018). At the time, there was an urgent need for low-cost solutions to care for low-birth-weight infants who were born prematurely. Inspired by kangaroos, who keep their young in a pouch for a long period after birth, Drs. Edgar Rey Sanabria and Héctor Martínez Gómez developed Kangaroo care to support low-birth-weight infants without needing incubators or hospitalization (Abadía-Barrero 2018).

The idea was that constant skin-to-skin contact with their parent(s) would help fragile infants regulate their body temperature, until they could learn how to do this on their own ( Baley 2015). The doctors reported significant success with Kangaroo care! Data showed Kangaroo care lowered newborn death rates, improved rates of breastfeeding, and prevented infections.

Researchers from outside of Colombia learned about this program and began implementing Kangaroo care in both resource-poor and well-resourced settings. In the late 1990s, the World Health Organization began promoting Kangaroo care as part of its strategy to lower rates of infant death and serious illness (WHO 2003).

Today, Kangaroo care is used around the world, and researchers continue to investigate ways to use the Kangaroo care model for very fragile newborns in NICU settings. The success of Kangaroo care highlights the lifesaving nature of skin-to-skin care!

Skin-to-skin contact and nursing instincts

In the 1970s, Ann-Marie Widstrom, a Swedish nurse-midwife and researcher, observed and charted patterns in the behaviors of babies placed skin-to-skin with their birthing parents immediately after birth ( Phillips 2013). Dr. Widstrom discovered that after being placed on the birthing parent's abdomen, babies (when undisturbed) move through nine distinct phases that include:

1. The birth cry

2. Relaxation

3. Awakening

4. Activity

5. Resting

6. Crawling up to the chest

7. Familiarization with the nipple

8. Suckling, and then...

9. Sleeping

Dr. Widstrom taught that if newborns are provided skin-to-skin contact immediately after birth, they can usually find the nipple, latch, and suckle without assistance. When hospital staff are educated about this normal and instinctive process, they can support the first feeding session without rushing or interfering.

What is routine practice today?

Research overwhelmingly supports skin-to-skin, and hospital practices have been slowly changing.

Depending on the country, rates of skin-to-skin care after a vaginal birth can range from 1% to 98%.

How does having a Cesarean birth impact skin-to-skin care?

In many hospitals, the routine care after a Cesarean is for the baby to be taken to a warmer in the operating room, where they are examined, cleaned, labeled, weighed, measured, clothed, and swaddled before being shown briefly to the parents. The baby is then taken to a nursery for further assessment and observation in a warmer, while the birthing parent is taken to a separate recovery room, with the separation typically lasting at least one to two hours.

Chances of receiving skin-to-skin care are much lower after a Cesarean than a vaginal birth. For example, in the U.S., the Centers for Disease Control (CDC) tracks skin-to-skin care in hospitals and birth centers, using the Maternity Practices in Infant Nutrition and Care Survey (mPINC™) (https://bit. ly/489BRhO). In 2022, 70% of hospitals said they practice routine, uninterrupted skin-to-skin contact for most babies born vaginally (for at least 1 hour or until the first feeding session). In contrast, only 50% of hospitals said they provide routine skin-to-skin care after a Cesarean.

How often are birthing parents separated from their infants after a Cesarean?

Unfortunately, routine separation can harm both birthing parents and infants. In a landmark study published in 2009, researchers randomly assigned birthing parent-baby pairs to several different groups, including one group in which birthing parents and babies were separated for two hours after birth. The researchers found that birthing parents and babies who were separated for two hours had a higher risk of lower parent-infant bonding outcomes one year later, as measured by having a third party (who was unaware of the separation status) review videos of parent-baby interactions ( Bystrova et al. 2009).

Today it is highly unlikely that a study like that would ever receive ethical approval. Any future research on parent-baby separation will likely come from animal research. In one animal study, baby horses (foals) were separated from their mothers for one hour after birth (intervention group) or left undisturbed with their mothers (control group). The separation increased the risk for poor bonding and other adverse social outcomes as the foals grew ( Henry et al. 2009).

Those of us who have experienced unwanted separation after birth may feel disheartened by these study results. But the good news is that human beings are resilient (including infants!), and although we should avoid being separated from our newborn infants, if possible, this does not mean that we cannot bond with our children after a temporary separation. This research just means we should try to prevent separation whenever possible-and it highlights the importance that hospitals should place on keeping parents and babies together.

The impact of racism on access to skin-to-skin care

Cesarean rates differ for different racial and ethnic communities in the U.S.-meaning that Black and Brown babies are less likely to have skin-to-skin care since they are more likely to experience a Cesarean birth. Here is a breakdown of the Cesarean birth rates in 2022 ( Hamilton, Martin, & Osterman 2023):

Black: 36.8%

Native Hawaiian or Other Pacific Islander: 32.5%

Asian: 33.5%

Hispanic: 31.7%

White non-Hispanic: 31.1%

American Indian or Alaska Native 29.5%

However, these factors alone do not explain the differences in Cesarean rates by race. Experts in racial health disparities such as Dr. Joia Crear-Perry, OB-GYN, and Founder of the National Black Equity Collaborative (which merged with RH Impact) often clarify with the explanation:

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

Researchers believe that the medical racism of healthcare providers (both systemic and individual prejudice) has led to higher Cesarean rates among Black and Brown birthing parents-and that this topic demands our attention ( Okwandu et al. 2022; Roth & Henley 2012).

To learn more about the impact of racism on pregnancy and childbirth care, visit our Signature Article, Evidence on: Antiracism in Health Care and Birth Work (https://ebbirth.com/antiracism).

Moreover, racism has led to lower rates of exclusive breastfeeding, or the practice of only nourishing a baby with human milk for at least the first six months of life, in Black and Indigenous communities compared to other groups ( Mieso et al. 2021). The reasons for this disparity are rooted in histories of enslavement, land theft, racism, racist institutional practices that destabilized family groups, and aggressive marketing of formula or distribution of formula by the government within these communities (Asiodu, Bugg, & Palmquist 2021; Chiang et al. 2021; Davis et al. 2021; Mieso, Burrow, & Lam 2021).

They found that providing skin-to-skin care after Cesarean was significantly associated with higher rates of starting breastfeeding, and exclusive breastfeeding-with the greatest impact among Black infants ( Merewood et al. 2019). Black babies who were roomed in with their parent were more than 1.54 times more likely to exclusively nurse than those who did not, and Black babies who had skin-to-skin care after Cesarean were 1.65 times more likely to nurse exclusively while in the hospital compared to those who did not ( Merewood et al. 2019).

So, what can birthing people of color do if they are concerned about access to skin-to-skin care, lowering their risk of Cesarean birth, or gaining enough support in nursing their baby? How can they protect their health and find the support and care they need? A few evidence-based suggestions include:

Seek out lactation support before giving birth.

Seek out care providers and birth workers who are Black, Indigenous, or people of color.

Seek out doula support.

Later in this article we discuss research on the role doulas can play in supporting skin-to-skin after Cesarean.

Doula care, especially from full-spectrum, community-based doulas who are Black, Indigenous, or people of color, can provide all pregnant families with additional emotional and social support before, during, and after birth.

See the EBB Signature Article, Evidence on: Doulas to learn more.

com is a great search directory for Black midwives and doulas.

What are the benefits of skin-to-skin care?

In 2016, Cochrane researchers combined the results from 46 randomized trials that included 3,850 birthing parents and their healthy infants ( Moore et al. 2016). Eight of the trials included Cesarean births, and six of the trials included late preterm births (infants born preterm but at greater than 35 weeks' gestation).

The researchers found strong evidence that skin-to-skin care influences breastfeeding. Birthing parents who had skin-to-skin care with their babies were 24% more likely to still be breastfeeding at one to four months after giving birth, compared to birthing parents who received routine hospital care. They also tended to breastfeed their infants longer, by 64 days on average. When the researchers looked at exclusive breastfeeding (breastfeeding with no use of formula) from six weeks to six months after the birth, they found that the birthing parents who had skin-to-skin care were 50% more likely to exclusively breastfeed.

Babies held skin-to-skin with their birthing parents were 32% more likely to breastfeed successfully during their first feed, and they also had higher blood sugar levels by more than 10 mg/dL. The difference in blood sugar levels is important because infants with low blood sugar may be given formula, a practice that can interfere with bodyfeeding. Overall, the babies that had skin-to-skin care had better combined scores for heart rate, breathing, and oxygen level during the first six hours after birth.

The researchers did not find any differences when they looked at skin-to-skin care beginning within 10 minutes of the birth or after 10 minutes of the birth, or when they compared less than one hour of time spent skin-to-skin to more than one hour. Almost all of the included studies began skin-to-skin care within one hour after the birth. Larger studies are needed to better understand any differences between birth, very early, and early skin-to-skin time, and differences between longer and shorter time spent skin-to-skin.

In a 2018 review, researchers suggest that while early skin-to-skin care is rarely provided to premature or ill newborns, that it may in fact benefit them ( Almgren 2018). Researchers have found higher cortisol (stress) levels in infants not held by their birthing parents after birth ( Elverson et al. 2012). And a large study in Canada found that critically ill babies had a higher mortality rate when they were separated from their birthing parent after birth ( Ray et al. 2012).

Research has also shown that skin-to-skin care can greatly improve the birth experience. The care that birthing people receive can have long lasting implications for their relationships and their psychological health across the life course, so it is important to pay attention to the experience of childbirth and to support practices that improve that experience ( Deys, Wilson, & Meedya 2021).

In a 2019 study of more than 3,000 participants, researchers found that people who had a Cesarean and held their child shortly after birth reported a better birth experience overall than those who birthed vaginally ( Brubaker et al. 2019). This team of researchers also found that birthing people whose care team included a doula or midwife were more likely to see and hold their newborn immediately after birth ( Brubaker et al. 2019). And in a study with more than 1,371 Israeli women, skin-to-skin care had the greatest positive impact on satisfaction among those who had a Cesarean ( Kahalon, Preis, & Benyamini 2021).

To summarize, the benefits of early skin-to-skin care include:

For birthing parents:

Longer duration of breastfeeding.

More likely to exclusively breastfeed.

Less chest engorgement/pain at three days.

Less anxiety three days after birth.

Higher satisfaction-birthing parents who held their baby skin-to-skin were six times more likely to want the same care vs. those who held their baby swaddled.

For babies:

More effective suckling during the initial breastfeeding session.

Less crying- babies who received skin-to-skin care were 12 times less likely to cry during the observation period.

Heart rate, breathing, and oxygen levels were more likely to remain stable.

A beneficial increase in blood sugar.

The benefits of skin-to-skin care are so clear that the World Health Organization recommends that ALL newborns receive skin-to-skin care, including low-birthweight and premature babies (WHO 2022). Skinto-skin should begin immediately after birth and continue uninterrupted for at least one hour or until the first feeding session for birthing parents who are breastfeeding or chestfeeding.

Are there any potential harms to keeping birthing parents and babies together for skinto-skin care?

The only risk to early skin-to-skin care is a rare event called sudden unexpected postnatal collapse (SUPC). This is when a seemingly healthy infant becomes rapidly unstable within the first two hours after the birth, often during the first feeding session. This event happens in three to five infants out of 100,000 births. Zero to 1.1 deaths due to SUPC are thought to occur for every 100,000 births ( Moore et al. 2016).

Researchers have proposed a few safety measures to decrease the risk of SUPC during skin-to-skin care ( Ferrarello & Carmichael 2016):

Increase the time that a nurse or midwife observes the birthing parent-infant pair during the first two hours after birth.

Educate the parents and the doula (if present) to recognize abnormal newborn appearance and behaviors-such as pale or bluish skin color, difficulty breathing, or limp muscle tone-and delay the use of smartphones until the first two hours after birth.

Elevate the head of the birthing parent's bed to between 35 degrees and 80 degrees so that the baby isn't lying flat down on the birthing parent's chest.

Educate the birthing parent about safe breastfeeding and check frequently to be sure that the baby's neck is straight, and that nose and mouth are not blocked.

What about after a Cesarean-are there any risks to keeping birthing parents and babies together after a Cesarean?

Some parents may not be able to independently care for their infants immediately or for several hours after a Cesarean. For example, if you received strong sedatives or were sleep-deprived for many hours before the Cesarean, you may need supervision or assistance in caring for your newborn.

Your level of awareness and ability to remain awake when caring for and feeding an infant must be assessed and closely monitored by nursing staff, especially when a Cesarean follows a prolonged labor or when sedative medicines were given ( Mahlmeister 2005).
Can Cesareans be performed in a way that encourages skin-to-skin care?
In a popular 2015 YouTube video, Sarah Cooke was recorded giving birth to her son via Cesarean. The drape was lowered so Sarah could watch as the doctor lifted her son's head out of the incision in her uterus. Then the baby seemed to join Sarah in the birthing process, helping 'birth himself' by wiggling onto her body. This video, viewed over 2 million times, received attention from publications like The Telegraph, as an alternative approach to Cesareans.

What made this birth so special that so many people tuned in to watch? Well, millions of people around the world have given birth by Cesarean, and some of them have told us that they wish they could have had a gentler birth experience, just like Sarah's.

We do not have much research on gentle Cesareans, but there is plenty of research on one important part of this practice-and that is skin-to-skin in the operating room!

What is the evidence for skin-to-skin care specifically for babies who are born by Cesarean?
Meta-analysis of randomized, controlled trials
Researchers have combined all the results from randomized trials on this topic into one large study, called a meta-analysis. The most important meta-analysis on this subject was published by Moore et al. in 2016, with a total of 46 studies.

Out of all the studies, 8 trials included participants who gave birth by Cesarean. The birthing parents received epidurals or spinals in seven of the trials and general anesthesia ("put to sleep") in one trial. None of the trials included emergency Cesareans, and all the infants were full term. Most of the time, skin-to-skin care was started in recovery room at about 50 minutes after the birth. Only one study started the skin-to-skin care in the operating room. Skin-to-skin care was usually provided for 30 to 80 minutes.

The researchers found that skin-to-skin care resulted in several benefits after a Cesarean birth. The infants who received skin-to-skin care were 22% more likely to still be breastfeeding one and four months after the birth. Seven out of eight studies also found an increase in exclusive breastfeeding at hospital discharge. Some parents also reported less pain after their Cesarean, but the evidence was not strong enough to show a clear effect on pain.
Reviews of observational research
The researchers found no significant differences in temperature, Apgar scores, oxygen levels, or heart rate in infants who had immediate skin-to-skin after Cesarean birth ( Frederick, Fry, & Clowtis 2020). The Apgar score (sometimes called the newborn Apgar score) is an assessment tool that healthcare providers use to check the baby's health shortly after birth (https://cle.clinic/3Lfhl5l). The Apgar score is used to determine whether or not a baby might need to be resuscitated or is having other health issues that might require closer monitoring or intervention.

The benefits to birthing parents who have skin-to-skin care after a Cesarean birth go beyond improved breastfeeding and reducing pain. In another review of 13 studies from around the world, researchers found that skin-to-skin care after Cesarean has a positive impact across cultures and across healthcare settings ( Deys, Wilson, & Meedya 2021).

For example, in one study of birthing parents who had skin-to-skin care after Cesarean, participants reported that the skin-to-skin care improved their birth experience and helped them feel secure and that their baby was safe ( Bertrand and Adams 2020). For those who had an unscheduled Cesarean, they credited skin-to-skin care with helping them cope with the unexpected way they gave birth (Bertrand and Adams 2020). It is important to note that the people in this study were not necessarily supported in seeking skin-to-skin, with participants noting that they had to advocate for themselves, sometimes even demanding skin-to-skin care. For those who had skin-to-skin care offered to them by their health care team, they reported feeling supported.

Individual studies on skin-to-skin care for babies born by Cesarean

Some individual studies have highlighted other benefits of immediate skin-to-skin care after a Cesarean, and we review their findings below:
Small, randomized trial found that skin-to-skin care led to earlier breastfeeding
In 2012, Velandia et al. randomly assigned 37 families planning a Cesarean to immediate skin-to-skin care with the birthing parent (who all self-identified as mothers) or immediate skin-to-skin care with the non-birthing parent (who all self-identified as fathers). In both groups, the baby was placed skin-toskin on the mother's chest within one minute after birth and stayed there for five minutes. Afterwards, the baby either remained there for 25 more minutes or was switched to the father's chest for 25 minutes. After this time, all the babies did skin-to-skin with their mothers for an additional 90 minutes.

Babies who spent skin-to-skin time with mothers breastfed significantly earlier than babies who had skin-to-skin with their fathers. There were no adverse effects reported. This study was limited by its lack of a true control group and because they did not report any measurements on infant temperature, breathing, or heart rate.
Larger, randomized controlled trial found that immediate skin-to-skin made a difference in breastfeeding outcomes
The largest randomized, controlled trial to examine immediate skin-to-skin care included 366 people having an elective Cesarean for a single baby at 37 to 42 weeks of pregnancy ( Gregson et al. 2016). The outcome that the researchers were most interested in was breastfeeding rates, so families who expressed a desire to formula feed their infants were excluded from the study.

Participants were randomly assigned to immediate skin-to-skin care in the operating room (182 families) or standard care (187 families). The group assigned to immediate skin-to-skin care received a KangaWrap Kardi to wear under the operation gown. The KangaWrap Kardi was a simple garment that was designed to help facilitate skin-to-skin care after Cesarean (this product no longer seems to be available). After birth, each baby was placed immediately on the birthing parent's chest, and families were encouraged to keep the baby skin-to-skin as much as possible during the first 48 hours. For ethical reasons, the standard care group also received the baby after birth and birthing parents were encouraged to have at least one hour of skin-to-skin time.

Not surprisingly, most participants assigned to the standard group also wanted to spend a lot of time skin-to-skin with their newborns. Because of this crossover, or 'contamination' of the standard care group, both groups spent a similar amount of time doing skin-to-skin.

When data from both groups were combined, they found that the length of time spent skin-to-skin was directly linked to the rate of continuing to breastfeed at 48 hours-with longer time spent skin-toskin leading to a higher rate of continuing to breastfeed at 48 hours. However, we don't know if more time spent skin-to-skin was a direct cause of breastfeeding success, or if the mothers who were more motivated to breastfeed chose to spend more time skin-to-skin.

This study provides evidence that most birthing parents desire skin-to-skin time with their newborns as soon as possible after Cesarean, that it is possible to safely practice skin-to-skin care in the operating room, and that more time spent skin-to-skin may benefit breastfeeding.

Small, randomized trial found that a gentle Cesarean approach and immediate skin-to-skin improved breastfeeding outcomes.

In 2016, Armbrust et al. randomly assigned 205 people at more than 37 weeks' gestation who were planning a Cesarean to either immediate skin-to-skin (along with a gentle Cesarean approach) or routine separation.

In the skin-to-skin group, a gentle Cesarean approach was used, which the researchers chose to call a Charité Cesarean. The surgical drape was lowered so that the family could see the birth, the infant was slowly delivered (also called "walked" out of the uterus) by the doctor, and the non-birthing partner was given the option to cut the umbilical cord. The naked infant was briefly examined and placed on the mother's bare breast and covered by a warm blanket. The baby remained skin-to-skin with the birthing parent for the rest of the surgical procedure and into recovery-a total of one hour or more.

In the routine separation group, the baby was taken away immediately for an assessment. The article does not specify when the babies in this group were returned to the parents.

The study found that parents who experienced the gentle Cesarean and immediate skin-to-skin care rated their birth experience much better than the group that had a routine Cesarean followed by immediate separation. Rates of breastfeeding were higher in the group that received immediate skin-toskin (81 vs. 69%), and they reported fewer problems breastfeeding. There were no adverse outcomes or differences in Apgar scores between groups.

Small, randomized trial found that immediate skin-to-skin after Cesarean may reduce stress hormones in birthing parents

A 2019 study randomly assigned 40 families into two groups: one group began skin-to-skin care immediately after Cesarean in the operating room, and one group received standard post-Cesarean care, where they could not begin skin-to-skin until the umbilical cord had been cut, surgery had been completed, and they had transferred to the recovery room bed, but could begin while still in the operating room ( Crenshaw et al. 2019).

The researchers measured each birthing parent's heart and breathing rate, oxygen saturation, temperature, blood pressure, and the amount of cortisol (the stress hormone) in their saliva to learn more about the effects of each approach to Cesarean ( Crenshaw et al. 2019). They took these measurements before surgery, about 20 minutes after birth, one hour after birth, and two hours after birth ( Crenshaw et al. 2019).

Results showed that birthing parents in the skin-to-skin care group had lower levels of stress hormones and higher blood oxygen levels compared to those who were separated from their infants. They found no major differences in newborn temperatures between groups. Although newborns in the skin-to-skin groups had initially lower temperatures in the operating room, their temperatures remained within the normal range ( Crenshaw et al. 2019).

Small, randomized trial found that very preterm babies benefited from skin-to-skin very early after

Cesarean birth

A study in Norway looked at the impact of skin-to-skin on very preterm infants born vaginally and via Cesarean to learn if this could benefit these fragile newborns ( Kristoffersen et al. 2023). The study included 108 infants born between 28 to 31 weeks' gestation, 62 of whom were born via Cesarean.

All the babies were first placed in a warming resuscitation unit for assessment and stabilization before being randomized into one of two groups:

1. Infants in the standard care group (57 babies) were immediately transferred to an incubator to be assessed before being moved to the NICU.

2. Infants in the skin-to-skin group (51 babies) were initially placed in the incubator for stabilization and assessment, and then as quickly as possible placed on the birthing parent's chest. These infants were able to remain skin-to-skin for up to two hours before being transferred to the NICU in an incubator.

The researchers found that rates of hypothermia (low body temperature) and hyperthermia (high body temperature) were lower in the skin-to-skin group than in the group placed in an incubator after birth (4% vs 7%; 26% vs. 47%) ( Kristoffersen et al. 2023). The infants who received skin-to-skin care were also more likely to be discharged early to home care. Over 50% of the infants in this study were born via Cesarean, leading researchers to suggest that it is safe for very fragile infants to receive very early skinto-skin care, whether they are born vaginally or via Cesarean.

Observational study suggests that skin-to-skin during Cesareans might decrease the likelihood of transfer to NICU

In a medical records study, researchers looked at four years of non-emergency Cesareans for infants born at 37 to 42-weeks' gestation at a single hospital in the U.S. ( Schneider et al. 2017). The first two years of data were from before the hospital began using immediate skin-to-skin during Cesarean, and the last three years of data were from after a new skin-to-skin care practice went into effect.

The researchers found that fewer newborns were transferred to the NICU for observation after the skinto-skin practice began (1.8 vs. 5.6%). There were no other policy changes over this time that could have impacted the number of babies sent to the NICU. The authors point out that fewer babies being sent to the NICU for observation could reduce costs for hospitals, since NICU observations are not always reimbursable.

Quality improvement studies of skin-to-skin after Cesarean

There are quite a few quality improvement reports in the literature in which hospitals describe implementing immediate skin-to-skin care during a Cesarean ( Brady, Bulpitt, & Chiarelli 2014; Boyd 2017; Hung & Berg 2011; Lanning et al. 2019; Moran-Peters et al. 2014; Smith, Plaat, & Fisk 2008; Sundin 2015). Quality improvement (QI) in healthcare refers to the process of using data to begin new processes or systems for providing care-and these new processes or systems are intended to improve patient outcomes, improve staffing, or address clinical problems.

In these QI reports on immediate skin-to-skin care after Cesarean, hospitals reported seeing improvements in breastfeeding rates as well as lower pain perception and anxiety, and higher satisfaction for birthing people. They found no adverse effects from using immediate skin-to-skin care in the operating room.

In 2012, researchers at a Texas hospital carried out an "intervention" to help staff increase the rates of immediate skin-to-skin care. After formal training sessions on the benefits of skin-to-skin, the researchers videotaped 11 births (five vaginal, six Cesarean) in which immediate skin-to-skin was used, and then they showed these videos to staff. The videos helped the staff discuss how they could make the process work smoother. Before the intervention, about 58% of birthing parents and babies had immediate skin-to-skin care. In the months afterwards, the rate of immediate skin-to-skin care increased to 83%. Almost all the increase was due to birthing parents who gave birth by Cesarean having immediate skin-to-skin in the operating room (the hospital did not routinely do skin-to-skin in the operating room before) ( Crenshaw et al. 2012).

I would like to have skin-to-skin care as soon as possible after my Cesarean, but my hospital says they won't let me. Why is that?

There are a few reasons that hospitals resist skin-to-skin care after Cesarean birth. Many hospital staff perceive that skin-to-skin care may be "risky" to the birthing parent or infant. They may worry that skin-to-skin care in the operating room may pose the risk of hypothermia (low body temperatures) for a newborn baby. Some staff may also think that the logistics are just too difficult to provide this type of care. And finally, skin-to-skin care in the operating room may be in conflict with the culture of the medical institution.

Here are some of the potential perceived barriers to skin-to-skin care after a Cesarean ( Balatero, Spilker, & McNiesh 2019; Hung & Berg 2011; Smith, Plaat, & Fisk 2008):

Concern that the birthing parent cannot hold the baby after Cesarean safely:

The birthing parent may not be capable of holding the baby due to nausea or other symptoms- in this case, another family member would need to do skin-to-skin with the baby.

Concern that the infant may to be too slippery to hold or lay safely on the operating table with their birthing parent.

Concern that skin-to-skin care after Cesarean requires too many staff:

Some hospitals may require a designated baby nurse to be in the operating room or the recovery room (in addition to the birthing parent's nurse) so a shortage of nurses may prohibit early skinto-skin care.

Nurses may face a new requirement to learn to 'scrub-in' for Cesareans to safely receive the baby through the drape.

Belief that skin-to-skin care interferes with 'business as usual' in the operating room:

The birthing parent's heart monitor stickers need to be placed on their sides, to leave a spot open on their chest for the baby.

The birthing parent's gown needs to be placed so that it easily opens for the baby to lay on their bare chest.

The birthing parent's blood pressure cuff and IV needs to be placed on the non-dominant arm.

The birthing parent's oxygen monitor needs to be put on their toe instead of their finger.

The baby needs to be dried and covered with multiple warm blankets (potentially bubble wrap) and a cap.

If the skin-to-skin time is done very early (in the OR), the baby may need to be laid crosswise across the birthing parent's upper chest, above the sterile drape.

Routine procedures, such as weight, measurement, and baby eye drops, need to be delayed.

Other routine baby procedures (Apgar scores, assessment, placing the ID bracelet) need to be done on the birthing parent's chest.

Bathing needs to be delayed, with priority given to the skin-to-skin time.

Now that we know the perceptions, it is time to consider what the research actually says. We outline some of the research on these perceived barriers below.

Baby's temperature

One of the main perceived barriers to providing skin-to-skin care after a Cesarean is because hypothermia (low temperature) in babies is more common after a Cesarean. In fact, many healthcare providers cite this as a safety concern ( Balatero, Spilker, &McNiesh 2019).

Babies who are born via Cesarean are at higher risk of hypothermia because the operating room temperature is kept quite cold, birthing parents may have a lower body temperature during a Cesarean, and babies were exposed in utero to medications that may affect their temperature ( Moore et al. 2016).

Time and space

A lack of space in the operating room is often listed as a barrier to skin-to-skin care in the operating room ( Balatero, Spilker, & McNiesh 2019). Length of time spent in the operating room is another logistical concern for immediate skin-to-skin care. One study of 110 people who had a planned Cesarean found that skin-to-skin care in the operating room did not impact time spent in the room ( Cuerva et al. 2022). The study did see an increase in the rate of breastfeeding at hospital discharge among those who had immediate skin-to-skin vs. those who did not have immediate skin-to-skin (74% vs. 57.4%) ( Cuerva et al. 2022).

Maintaining the sterile field

There were no differences in blood loss and no differences in the need for blood transfusion. The length of time spent in surgery and the average recovery time were both shorter in the immediate skin-toskin group. Of the infants in the study, those who received immediate skin-to-skin care had fewer admissions to the NICU (9.5% vs. 18%), and fewer suspected infections (2.0% vs 7.3%). The rate of low Apgar scores at 5 minutes after birth were not significantly different between groups (1.5 to 2.4%). Overall, these results suggest that immediate skin-to-skin care does not increase the risk of infection or lengthen the time spent in surgery ( Posthuma et al. 2017).

Hospital culture

For change to take place in a hospital, it requires a shift from "how it has always been done" to what the current evidence shows is best for families. This change can be helped along by dedicated nurses or physicians who are seen as leaders by their peers.

In Michigan, Dr. Tami Michele successfully led the charge to convert Spectrum Health Gerber Memorial hospital over to routine skin-to-skin care after Cesarean. Dr. Michele started by approaching the anesthesia providers, since their workspace at the head of the birthing parent's bed was most affected by the changes in patient monitoring. She provided information on the benefits of skin- to-skin care after Cesarean and details about how procedures would change. Dr. Michele presented the change from the perspective of improving the Cesarean patient's experience. She brought everyone to the table- past patients, doulas, nurses, anesthesia providers, lactation consultants, clinical supervisors, childbirth educators, marketing directors, surgical staff, and hospital administration-so that the entire team felt ownership of the changes they were about to create.

It's important to address everyone's concerns to get staff completely on board with the new way of providing care. For example, physicians may think that they need the newborn's weight right away to complete the patient's chart. However, the record could be completed later or documented as "weight pending due to skin-to-skin." Education for staff can be helpful to decrease anxiety around making changes (Personal correspondence, Michele 2017).

Is it possible for hospitals to keep birthing parents and babies together in recovery after a Cesarean?

Yes. For example, at Spectrum Health Gerber Memorial hospital in Michigan, birthing parents are admitted to the room they will be in during their hospital stay for a planned cesarean. The preoperative procedures are done there. After the surgery, the parents and baby return to that same room for immediate post-operative recovery. Other family and friends are asked to wait to visit until the surgical recovery time is completed. The birthing parent and partner continue skin-to-skin and initiate breastfeeding (if the baby had not already started breastfeeding during the surgery). The baby only goes to the nursery if there is a medical emergency (Personal correspondence, Michele 2017).

Another interesting quality improvement report was published by Elliott-Carter & Harper in 2012. This report described how nurses at Woman's Hospital in Baton Rouge, Louisiana led a switch from routine separation after Cesareans to keeping birthing parents and babies together. The hospital was motivated to change for several reasons, including a desire to stay competitive with other hospitals and repeated requests from clients to not be separated from their babies. Perhaps most compelling, the staff felt it was simply "not fair" that birthing parents who gave birth vaginally were allowed to stay with their babies, while birthing parents who had Cesareans were automatically separated from their babies. The Cesarean rate at Woman's hospital was 40%, and they have more than 8,000 births per year. So, making this change affected 3,200 families per year.

One of the first things the hospital did was put together a leadership team to plan for the change. A major challenge for this team was finding a space that was large enough for birthing parents and babies to recover together after a Cesarean. They ended up choosing overflow labor and delivery suites that were big enough for this purpose. They also modified the existing recovery room (Post Anesthesia Care Unit, or PACU) so that it could be used in case the overflow rooms were full.

The team had to train the recovery (PACU) nurses in neonatal resuscitation. They placed baby blankets in the heated blanket warmer and stocked appropriate medications for both birthing parents and babies in each room.

Perhaps most importantly, staff made a commitment to provide care where the birthing parents and babies were. Although taking the baby to the nursery was easier and more convenient for the staff, they realized that keeping parents and babies together was best for everyone.

In the first year after starting this project, the percentage of infants who were separated from their birthing parents dropped from 42% to only 4%. Nurses stated that everyone was extremely satisfied with the change-including staff, physicians, and families. Nurses also reported that birthing parents can have skin-to- skin contact earlier, and that the first breastfeeding session goes smoother.

As nurses from the Woman's Hospital said, "If a hospital that delivers 8,000 infants annually can find a way to decrease the separation of birthing parents and newborns, concerned nurses everywhere should be able to implement this type of care."

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The Evidence for Skin to Skin Care after a Cesarean

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What is the evidence for Skin-to-Skin care after a C-section? Can I have skin-to-skin care with my baby in the operating room after a Cesarean?

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The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance. This section should be read in conjunction with 'Antenatal care: routine care for the healthy pregnant woman' (NICE clinical guideline 62) and 'Intrapartum care: care of healthy women and their babies during childbirth' (NICE clinical guideline 55).

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Considering a caesarean birth patient information leaflet | RCOG

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This information is for you if you are considering a planned (elective) caesarean birth for your baby. It may also be helpful if you are a partner, relative or friend of someone who is considering a caesarean birth.

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Welcome Birth stories can be really inspiring when you're preparing for your own induction. I remember searching for positive induction stories before my first birth and struggling to find th...

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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.

You will usually stay in the hospital maternity unit while you wait for it to work.

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.

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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Ten Things...I wish every woman knew about induction of labour | AIMS

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Over 7,500 babies are born in Oxfordshire every year. Our vision for every mother is to experience excellent personalised care from the right professionals, through pregnancy, birth and beyond. We strive to deliver real choice and continuity of carer.

We are also a regional referral unit for women with higher-risk pregnancies, and our Newborn Care Unit provides special care for babies in Oxfordshire and across the South East.

We encourage women with low-risk pregnancies to have their babies at home or in one of our midwifery-led units; however, it is your choice where to give birth, and your choices include the Delivery Suite at the John Radcliffe Hospital.

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Copyright (c) 2019 Oxford University Hospitals NHS Trust

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Over 7,500 babies are born in Oxfordshire every year. Our vision for every mother is to experience excellent personalised care from the right professionals, through pregnancy, birth and beyond. We strive to deliver real choice and continuity of carer.

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The mode of delivery has a big impact on an infant's microbiota, the bacteria that live in the gut. Martin Valigursky/Shutterstock

Our gut does more than help us digest food; the bacteria that call our intestines home have been implicated in everything from our mental health and sleep, to weight gain and cravings for certain foods. This series examines how far the science has come and whether there's anything we can do to improve the health of our gut.
We used to think foetuses had no bacteria in their gastrointestinal tract (the gut) until they began to accumulate microbes (bacteria, viruses and other bugs) on their way through their mother's vagina.

But this theory was challenged when bacteria was found in meconium (the first poo) of premature babies. This, of course, travelled through the gut, accumulating microbes on the way.

What's clear is that newborns have little (if any) diversity in their microbiota - the collection of bacteria that accumulate in the gut. This increases as they're exposed to different environments.

The particular makeup of a newborn's gut microbes is important as it has been shown to affect their risk of developing certain diseases in childhood and adulthood.

Vaginal or caesarean birth?

The mode of delivery has a big impact on an infant's microbiota. During natural delivery, the direct contact with the mother's vaginal and intestinal flora help shape a newborn's gut bacteria colonisation. Newborns delivered via caesarean section don't have this direct contact.

One study found that newborns born vaginally were colonised by Lactobacillus whereas caesarean delivery newborns were colonised by a mixture of bacteria typically found on the skin and in hospitals, such as Staphylococcus and Acinetobacter.

These early differences tend to be sustained. One study showed the distinct gut flora of infants born by caesarean delivery persisted at six months after birth. Faecal Clostridia numbers in seven-year-old children born vaginally were found to be significantly higher than in children of the same age born via caesarean.

But we still don't know how this impacts on children's health and the risk of disease.

The developing immune system

We're beginning to realise gut bacteria plays an important role in the growth of infants' immune systems. One way this could occur is by altering the development of the white blood cells that provide a first-line defence against invading microbes: bugs that make us sick.

Research shows mice born in a germ-free environment have fewer of these white blood cells compared to healthy mice with a normal gut bacteria population. Such mice are also more prone to bacterial infection.

Allergic diseases such as asthma and hay fever appear more often in infants after caesarean delivery than after vaginal delivery.

kritsada doungdao/Shutterstock

Children born by caesarean delivery are also significantly more likely to be hospitalised for acute gastroenteritis and to develop coeliac disease.

It's important to note that not all caesarean deliveries are the same. Some women have caesarean sections after a long labour where her waters have broken. In this case, the infant would be exposed to quite a different microbial environment than a planned caesarean section carried out before her waters have broken.

Breast- or bottle-fed?

Breast-fed newborns have a distinctly different gut microbiome to other newborns. They have higher proportions of the beneficial bacterial species Bifidiobacterium than formula-fed infants. This is likely due to breast milk containing a type of prebiotic that facilitates the growth of bacteria such as as Bifidobacterium.

Interestingly, when breast-fed infants are supplemented with formula feeds, their gut microbiota resembles infants who are exclusively formula-fed.

What does this mean for infants' risk of developing disease?

A US study has shown that breast-fed babies had a gut microbiome that was richer in genes associated with "virulence": the ability to fight off antibiotics and toxic compounds. These same babies also developed changes in the genes of their gut immune system that allowed them to better fight off infection.

This suggests that breast milk can promote a healthy crosstalk between the baby's immune system and the gut microbiome.

DeymosHR/Shutterstock

Breast-feeding has been shown to reduce the development of necrotising enterocolitis (where parts of the bowel die off) in newborns, allergic and autoimmune diseases in childhood, including coeliac disease, type 1 diabetes and asthma.

Vaginal seeding

What if your child is born via a caesarean section and can't be breastfed?

Don't worry, not all such infants will be at a greater risk of developing autoimmune and allergic diseases. A whole host of environmental and genetic factors play a role in determining individual risk.

Vaginal seeding has recently been proposed as one way infants born by caesarean section might gain some of the protective effects of environmental exposure for their gut microbiota.

A proof-of-concept study in 18 infants published earlier this year showed that transferring vaginal fluid to newborns (via a swab across their mouth, nose and face) shortly after delivery by caesarean section can result in microbiome profiles resembling that of infants delivered vaginally.

It is unknown though whether colonisation in this way is partially or fully equivalent to the microbial transfer at labour. We also don't know whether later health outcomes in these infants are affected by the practice.

Some expert clinicians warn against vaginal seeding because of the potential for unrecognised infections to be transmitted from mother to newborn. There is a risk, for example, of transmitting undiagnosed group B Streptococcus to newborns, given 12 to 15% of women have this organism in vaginal fluid.

Better ways to catch up

For now, it's more sensible to focus on the practices that have been shown to promote microbiome development in newborns delivered by caesarean. These include delaying the first bath until after 12 hours, placing the newborn on the mother's skin in the first few minutes after delivery and breastfeeding in the operating room, if permissible.

Kati Molin/Shutterstock

There has been much effort made in simulating the composition of human milk through adding live gut bacteria (probiotics) as well as non-digestible fibres (prebiotics) to formula. This is thought to assist microbial colonisation and immune responses in formula-fed infants in a similar way to breast feeding.

But hard data is lacking though on whether this approach can lead to a real-life benefit, particularly when it comes to reducing the risk of allergic disorders.

Fortunately, a large clinical research project in New Zealand - the Probiotics in Pregnancy study - will soon be able to answer this question.

Four hundred pregnant women expecting infants at high risk of allergic disease were given either a probiotic Lactobacillus rhamnosus or placebo - 14 to 16 weeks into their pregnancy until they gave birth, or for six months after if they breast-fed.

The researchers will then check if the infant develops allergies such as eczema. The results will be available before too long and may be instrumental in helping to shape health policy.
Read the other articles in our Gut series here.

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Gut instinct: how the way you're born and fed affect your immune system

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Our gut does more than help us digest food; the bacteria that call our intestines home have been implicated in everything from our mental health and sleep, to weight gain and cravings for certain foods. This series examines how far the science has come and whether there's anything we can do to improve the health of our gut.

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Monitoring your baby's heartbeat in labour

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Monitoring your baby's heartbeat in labour

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Monitoring a baby's heartbeat during labour aims to help to assess the baby's well-being and to see how well she or he is coping with labour.

For a healthy woman with a normal pregnancy the outcomes for the baby are generally very good. Monitoring is therefore aimed at trying to identify the rare baby who is not coping with labour and needs help.

A baby will struggle if his or her oxygen supply is insufficient for his or her needs and this can happen with the contractions in labour for a small number of apparently healthy babies. Where there is a major problem identified, these babies can benefit from a caesarean or instrumental birth (with forceps or ventouse). However, when the signs are unclear, a caesarean or instrumental birth may provide no benefit for the baby yet potentially have a negative effect on the mother's physical and emotional well-being, cause injury to the baby, and possibly put future pregnancies at risk. For this reason, it is important that monitoring is used appropriately.

This article aims to explain the methods that are available and the pros and cons of each. Some women find being monitored reassuring, others will find it intrusive. As with any medical procedure, it is up to the mother whether she agrees to any form of monitoring, and she can change her mind about this at any time.

W hat does heartbeat monitoring show?

All forms of heartbeat monitoring in labour are looking for changes in the baby's pattern of heartbeats that suggest he or she is not coping well with the contractions.

It is normal for a baby's heart-rate and beat pattern to vary during labour. When someone runs up a flight of stairs, their heart-rate will become faster and this is not a sign of problems but rather a sign of a healthy response to a stimulus. Similarly, some of the changes in a baby's heartbeat during labour are a normal response to labour contractions. It is important to distinguish between the normal heartbeat patterns for a healthy baby going through labour, and responding appropriately to the contractions from those which suggest that the baby is struggling. Sometimes these differences are clear, but often they are not, and research over the years has shown that the link between a baby's heartbeat patterns in labour and a baby's well-being is not straightforward, and the heartbeat patterns can be difficult to interpret, despite all the research in this area over the years.

The following information explains, briefly, the types of monitoring available, what the research evidence tells us and how you might use this information to make informed decisions about monitoring your baby's heartbeat in labour.

What is being looked for with the monitoring?

When interpreting the baby's heartbeat in labour, caregivers look at four features: Baseline rate (how fast the heart is beating between contractions); baseline variation (the ups and downs in the baseline rate); accelerations (an increase in the heart-rate in response to a contraction - generally a sign of a healthy baby) and the presence or absence of decelerations (a slowing of the heart-rate during or after a contraction). NICE recommends categorising these measurements as either reassuring (meaning there is no cause for concern); non-reassuring (meaning there is possibly a cause for concern) or abnormal (which can be subdivided into those cases that need further tests or those that need urgent intervention).

A non-reassuring heartbeat can sometimes be corrected by something as simple as the mother changing position, especially to some kind of upright position. It may also be worth checking whether the mother is well hydrated, or extremely anxious, as these might affect her blood pressure and therefore the baby's well-being.

How can a baby's heartbeat be monitored?

There are several ways of monitoring a baby's heart-rate. When choosing a place for birth, it is helpful to discuss monitoring with a midwife as some forms of monitoring are not available in all birth settings. Also, some monitoring might interfere with your freedom of movement and the types of coping strategies you want to use in labour.

Pinard or fetal stethoscope: This is a small device (a bit like an old-fashioned ear-trumpet) which is held against the mother's abdomen by the midwife, who listens to the baby's heartbeat for a minute or so at regular intervals. It is one form of what is called intermittent auscultation (IA).

Sonicaid - (or hand-held Doppler): This is an ultrasound device, held against the mother's abdomen, allowing both midwife and parents to hear the baby's heartbeat. Like a Pinard, it is used intermittently.

Cardiotocography (CTG) is a form of electronic fetal monitoring (EFM) which is usually used continuously. When continuously monitoring it provides a paper trace using Doppler ultrasound to record the baby's heartbeat and a pressure transducer to record the mother's contractions. The most common form (called external CTG) is where two separate probes to measure the heartbeat and the contractions are applied to the mother's abdomen and held in place by belts. In internal CTG a single probe to measure both heartbeat and contractions is attached directly to the baby's head (or bottom if the baby is breech.) For either external or internal CTG the probes are usually attached to the recorder by long wires.

Telemetry CTG (without wires) is sometimes available and with this cordless form of CTG it is easier for the mother to move and adopt positions she finds comfortable. It can also be used in a birth pool. NICE recommends telemetry if continuous monitoring is used but it isn't always available. You may want to check the availability in your local hospitals.

If there is concern about the baby's heartbeat in labour sometimes the doctor might suggest taking a fetal blood sample (FBS) to test for acidosis (whether the baby's blood is too acidic), which can indicate a shortage of oxygen. This is done by taking a tiny blood sample from a small scratch on the baby's head (or bottom). This is quite an invasive procedure but is recommended by NICE in certain situations although the evidence to support its use is not conclusive.

What are the pros and cons of intermittent monitoring?

Intermittent monitoring (sometimes called intermittent auscultation, or IA) enables the mother to move freely in labour and to adopt the positions she finds most helpful, and can also be used in a birth pool.

Research suggests that for women and babies at low risk of complications, intermittent monitoring is as effective as continuous monitoring at identifying babies who need help, but results in fewer caesarean or instrumental births. Data from a large-scale summary of many trials comparing intermittent and continuous monitoring showed that no differences were identified in the number of babies who died, developed cerebral palsy or other disabilities nor in the number with evidence of having actually been distressed in labour. Slightly more babies who had intermittent monitoring experienced fits in the new-born period compared to the continuous monitoring group, but there is no evidence that these fits had any long-term consequences, and the risk of fits was very low in both groups (1 in a 1000 with CTG versus 3 in a 1000 with intermittent monitoring.

As a result of these findings NICE recommends:

that IA (intermittent monitoring) is offered to women at low risk of complications in in all birth settings;

that IA is undertaken immediately after a contraction listening for at least one minute and repeating at least every 15 minutes.

CTG is not used in women at low risk of complications.

What are the pros and cons of continuous monitoring?

Continuous monitoring allows a midwife or doctor to track how the baby's heart is responding at all times, and also to look back at the history of how it has changed through labour in response to the mother's contractions. This information is often used to make decisions about when to intervene in the labour. However, as described above, evidence from multiple trials showed that continuous CTG compared to intermittent monitoring increased the incidence of caesarean births and the use of forceps or ventouse, but there was no difference identified in the number of babies who died nor in the number with cord blood acidosis (a sign of the baby not coping).

For some women, having continuous monitoring will be reassuring as it enables them to hear their baby's heartbeat, and mothers have the right to ask for this even if there are no risk factors.

External CTG may restrict the mother's movements in labour as the probe needs to be kept over the baby's heart. Some midwives therefore prefer a mother to lie down when using external CTG, but in fact this is not necessary. There is evidence that being able to use upright positions is helpful in labour so if the mother wants to do this, she or someone else can hold the probes in place, or they can be readjusted if they slip. Unless telemetry is used, the mother's movements will also be somewhat restricted by the leads.

Internal CTG does not restrict women's movements as much as external CTG (although movement is only possible as far as the length of leads), and there's less chance of the electrode coming off. However, it does require the waters to have broken (or been broken artificially) and a scalp electrode to be attached to the baby's presenting part - either the head or the bottom by means of a hook. This is painful for the baby, sometimes leaves a scar and potentially carries a risk of infection, though the evidence for this is not clear. Women who are HIV positive should not have internal CTG as it creates an open wound on the baby.

Once either external or internal CTG monitoring has been started, it is usually used continuously through labour, although the mother can decide to discontinue it. Unless telemetry CTG is available it will not be possible for the mother to be monitored continuously in a birthing pool. Also, continuous CTG is not available at homebirths and probably not in most midwifery-led units (MLUs) so if a mother in one of these settings agrees to having continuous CTG then she will usually need to transfer to a hospital obstetric unit.

What about women and babies at increased risk of complications?

Continuous CTG is recommended by NICE if certain risk factors are identified. These include having an epidural and/or an oxytocin drip to speed labour up; if thick or lumpy meconium is seen; if the mother has high blood pressure; high pulse rate or high temperature; starts bleeding; or her labour is considered to be too slow. There is no clear research to support this recommendation, but this is considered by the NICE guideline development group to be "best practice".

If continuous CTG is suggested, then it is important that caregivers explain why, and if they say there is an increased risk for the baby, you might want to ask how much the risk is increased, what the specific level of risk is, and how CTG will reduce that risk, before you make your decision as to whether or not to have CTG.

Continuous CTG might also be suggested if there are concerns about the baby's heartrate, but in this case NICE recommends that the first step is more frequent intermittent monitoring of the baby's heartbeat and a review of the whole clinical situation, including things like whether the mother is well-hydrated., Changing position might be all that is required, especially if the mother is lying on her back. Only if concerns continue, NICE advises that CTG be suggested. In this situation caregivers must explain the reasons why they think it is needed and respect the mother's decision whether or not to have continuous monitoring. NICE also recommends that if the CTG trace is normal after 20 minutes then intermittent monitoring should be resumed, unless the mother chooses to remain on the CTG.

What about monitoring on admission to the hospital?

It used to be common practice for women arriving at hospital in labour to be monitored continuously for 15-20 minutes, in the hope that this would identify babies who were at risk, and this may still be the practice in some units. However, for women and babies at low risk of complication, the evidence shows that this practice probably increases the number of caesarean births but with no differences identified in outcomes for the baby when compared with using a Pinard or hand-held Doppler for a minute or so. Using CTG on admission also increased the use of continuous CTG and Fetal Blood Sampling in labour. NICE therefore recommends listening to the baby's heart with a Pinard or hand-held Doppler for at least one minute at first contact between the woman and her midwife, whether at home for a homebirth, or on admission to a MLU or obstetric unit..

NICE states that continuous CTG should not be offered to women at low risk of complications in established labour. If an admission CTG is suggested your caregivers should explain the reasons for this, and it will be your decision whether to accept it.

In summary

Intermittent monitoring is recommended by NICE for women and babies at low risk of complications, both on admission and during labour. NICE also provides guidance on risk factors when continuous monitoring should be offered, however there is no clear evidence as to whether it is beneficial in these circumstances.

If continuous monitoring is suggested you may want to ask your caregivers for a clear explanation of the reasons, potential benefits and potential repercussions of having it in your particular circumstances, before deciding whether or not to agree. You can decide to start or discontinue any form of monitoring at any time.

References

1. NICE "Intrapartum: Care for healthy women and their babies during childbirth" CG190, Full guideline - update 2017. https://www.nice.org.uk/guidance/cg190/evidence/full-guideline-pdf-248734770

2. Devane D and Lalor J "Midwives' visual interpretation of intrapartum cardiotocographs: intra- and inter-observer agreement." J Adv Nurs 2005 Oct 52 (2) 133-141 https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2005.03575.x

3. NICE IPC CG190 Recommendations - update 2017 https://www.nice.org.uk/guidance/cg190/chapter/Recommendations

4. NICE "Intrapartum care for healthy women and babies - Information for the Public" - update 2017 https://www.nice.org.uk/guidance/cg190/ifp/chapter/Care-of-women-and-their-babies-during-labour-and-birth

5. East CE et al. "Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace." Cochrane Database of Systematic Reviews 2015, Issue 5 http://www.cochrane.org/CD006174/PREG_use-of-fetal-scalp-blood-lactate-for-assessing-fetal-well-being-during-labour

6. Alfirevic et al: "Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour." Cochrane Database of Systematic Reviews 2017 http://www.cochrane.org/CD006066/PREG_continuous-cardiotocography-ctg-form-electronic-fetal-monitoring-efm-fetal-assessment-during-labour

7. Lawrence et al. "Maternal positions and mobility during first stage labour." Cochrane Database of Systematic Reviews2013, Issue 8. http://www.cochrane.org/CD003934/PREG_mothers-position-during-the-first-stage-of-labour

8. Harper et al Cahill AG "The Risks and Benefits of Internal Monitors in Laboring Patients"Am J Obstet Gynecol. 2013 Jul 209 (1) 38e1 -b38 e6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760973/

9. Devane D, Lalor JG, Daly S, McGuire W, Cuthbert A, Smith V. "Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing". Cochrane Database of Systematic Reviews2017, Issue1 http://www.cochrane.org/CD005122/PREG_comparing-electronic-monitoring-babys-heartbeat-womans-admission-labour-using-cardiotocography-ctg

Written by: Gill Gyte
Reviewed by: Nadia Higson & Emma Ashworth
Reviewed on: 06/04/2020
Next review needed: 06/04/2022

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

Published on 23rd March 2017

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Monitoring your baby's heartbeat in labour

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Monitoring a baby's heartbeat during labour aims to help to assess the baby's well-being and to see how well she or he is coping with labour. For a healthy woman with a normal pregnancy the outcomes for the baby are generally very good.

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This information covers:

There can be many reasons for needing help with the birth of your baby. The main ones are:

there are concerns about your baby's wellbeing during birth

your labour is not progressing as would usually be expected

you are unable to, or have been advised not to, push during birth

Overall about 1 in 8 (10-15%) births in the UK will be an assisted vaginal birth although this is much less common in women who have had a vaginal birth before. 1 in 3 women having their first baby will have an assisted vaginal birth. Your healthcare professional will discuss ways to reduce your chance of needing an assisted vaginal birth during your pregnancy.

If you have someone supporting you throughout your labour, you are less likely to need an assisted vaginal birth, particularly if the support comes from someone you know, in addition to your healthcare professional.

Assisted vaginal births are less likely if you do not have any complications in your pregnancy and plan to have your baby in a midwife-led unit. Using upright positions or lying on your side after your cervix is fully open in labour can reduce the need for an assisted vaginal birth. Having an epidural for pain relief in labour may increase the chance of you needing an assisted vaginal birth, but this is less likely with modern epidural anaesthetics.

The need for an assisted vaginal birth may be reduced by not starting to push too soon after your cervix is fully open. You may be advised to wait until you have a strong urge to push, or to try and delay pushing by 1-2 hours depending on your individual situation.

A ventouse (vacuum cup) is an instrument that uses suction to attach a plastic or metal cup on to your baby's head. Your healthcare professional will wait until you are having a contraction and then ask you to push while they pull to help you give birth. This may happen over several contractions. Sometimes the cup can detach itself, making a "pop" sound. If this happens your healthcare professional may need to re-apply the cup to your baby's head before continuing.

Forceps are smooth, curved metal instruments. They are made to carefully fit around your baby's head. Your healthcare professional will wait until you have a contraction and then ask you to push while they pull with the forceps to help you give birth. This may happen over several contractions.

Ventouse and forceps are both safe and effective. Choice of instrument depends on factors including how well your epidural is working (if you have had one), the wellbeing of your baby and the position of your baby's head. If you need an assisted vaginal birth at less than 36 weeks of pregnancy, forceps may be preferred over ventouse. This is because they involve less risk of injury to your baby's head which is softer at this stage of pregnancy.

Your healthcare professional will recommend the method most suitable for your individual situation. If you have any concerns around the use of ventouse or forceps you should discuss this with your healthcare professional at any time during your pregnancy or labour.

If one instrument has been chosen and is not effective, your healthcare professional may then either recommend using the other instrument to help you have a vaginal birth or offer a caesarean, depending on your individual circumstances.

If neither instrument is effective in helping you give birth, your healthcare professional will recommend an emergency caesarean birth.

Forceps and ventouse will only be recommended if they are thought to be the safest way to help you give birth. The reasons for recommending an assisted vaginal birth, the choice of instrument and the procedure will be discussed with you at the time. If you are in labour and choose not to have an assisted vaginal birth, the alternatives are to wait for your baby to be born without assistance or to have an emergency caesarean. Your healthcare professional will discuss your options depending on your individual circumstances.

A caesarean in the late stage of labour is a more complex operation than a planned caesarean and in some circumstances may increase the risk of harm to both you and your baby.

Decision making in labour can be difficult which is why it is important to explore any concerns you may have with your healthcare professional before you go into labour.

If you are certain you would not want an assisted vaginal birth, one option is to choose a planned caesarean birth before you go into labour. If you are considering a planned caesarean you should discuss this with your healthcare professional during your pregnancy. For more information, refer to the RCOG patient information on caesarean birth.

With your consent, your healthcare professional will examine your abdomen and perform an internal examination to confirm that an assisted vaginal birth is safe for you and your baby. You will usually be asked to sit with your legs supported and your bladder will be emptied by passing a small tube (catheter) into it.

Pain relief for the birth may be either a local anaesthetic injection inside the vagina or a regional anaesthetic injection into your back (an epidural or a spinal). For more information about pain relief during labour see the Labour Pains website ( labourpains.com) from the Obstetric Anaesthetists' Association.

You are more likely to need to have a cut (episiotomy) to enlarge your vaginal opening and allow your baby to be born.

A healthcare professional who specialises in the care of newborn babies may be there when you give birth in case your baby needs some extra help after birth. If your baby is well you may choose to have immediate skin to skin contact and/or delayed cord clamping.

After your baby is born you will be given some antibiotics through a drip to reduce the chance of you developing an infection.

If your healthcare professional expects your assisted vaginal birth to be straightforward, they will recommend that you give birth in the same room where you have been in labour. If they think that the assisted vaginal birth may be more complicated or that there is a chance that it might not work, you will be advised to give birth in the operating theatre. This is so that you can have an immediate caesarean if necessary.

Assisted vaginal birth is less likely to be successful if:

you are overweight with a body mass index (BMI) over 30;

you are less than 161cm in height

your baby is estimated to be more than 4kg in weight

your baby is lying with its back to your back at the end of your labour

your baby's head is not low down in the birth canal at the end of your labour

You may need to stay in hospital for longer than originally expected after the birth of your baby.

A third- or fourth-degree tear (a tear which involves the muscle and/or the wall of the anus or rectum) affects 3 in 100 women (3%) who have a vaginal birth. It is more common following a ventouse birth, affecting up to 4 in 100 women (4%) and following a forceps birth, affecting between 8 and 12 women in every 100 (8-12%).

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Assisted vaginal birth (ventouse or forceps)

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This information covers: There can be many reasons for needing help with the birth of your baby.

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AIMS - support for your rights in childbirth 

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AIMS - support for your rights in childbirth 

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What is delayed (or opitmal) cord clamping (DCC)?

The umbilical cord links your placenta to the baby. After your baby has been born, the umbilical cord continues to pulsate. This is because it is still transferring blood, oxygen, and stem cells to your baby while they adjust to being outside the womb.

It used to be common practice to cut the umbilical cord straight after your baby is born. Now guidelines say that delayed (or optimal) cord clamping is better for your baby.

It is normal practice to wait until the cord has stopped pulsating and becomes white before cutting the cord. Normally the midwife should be able to feel when this happens by just touching the cord. This is called delayed (or optimal) cord clamping.

The cord should not be clamped earlier than 1 minute after birth.

It’s recommended that the cord is clamped before 5 minutes (so the placenta can come out after it has separated from the uterus), but you can ask for it to be clamped and cut later than this.

Your doctor or midwife may need to clamp the cord earlier if there is a problem. For example, if there are concerns about your baby’s heartbeat and they need breathing support.

You do not have to have delayed cord clamping if you don’t want it.

You can have delayed cord clamping if you have active or physiological management to deliver the placenta after giving birth. Find out more about delivering the placenta.

Can I or my birth partner still cut the cord if we have delayed (or optimal) cord clamping?

You or your birth partner can still cut the cord if you have delayed cord clamping, if this is what you want.

Can I still have delayed (or optimal) cord clamping  if I am HIV positive?

You may still be able to have delayed cord clamping if you are HIV positive. Evidence shows that the benefits of delayed cord clamping outweigh the risk of HIV transmission if the mother has been taking antiretroviral medications.

If you are HIV positive, make sure your healthcare team is aware as early as possible in your pregnancy. They can help get the treatment you need to reduce the risk of passing the infection to your baby.

Why is delayed (or optimal) cord clamping recommended?

The benefits of delayed cord clamping include:

increased iron levels in the baby even up until they are 6 months old, which helps with growth and both physical and emotional development

increased amount of stem cells, which helps with your baby’s growth and helps with their immune system.

There is also some research that suggests that delayed cord clamping can improve the health of premature babies.

When is delayed (or optimal) cord clamping not recommended?

In most situations, delayed cord clamping is beneficial and will be recommended. But there are some circumstances where it may not be suitable, such as:

if the person giving birth is bleeding heavily and need immediate medical treatment

if there is an issue with the placenta, such as placental abruption, a low-lying placenta or placenta praevia, vasa praevia

if the cord is bleeding so the blood is not getting to the baby

if they baby needs help to breathe (resuscitation).

Twins who share the same placenta (monochorionic twins) should not have delayed cord clamping. This is because there is a small risk that blood could move from one twin into the other during the birth.

Find out more about multiple pregnancies.

What if my baby needs help breathing at birth?

Sometimes babies need additional support when they are born. Midwives and doctors are trained to make decisions to help babies adapt to the outside world. It may be possible to help your baby without cutting the cord.

If they can, your healthcare team will provide any immediate care that your baby needs and keep baby close to you while the cord is intact. Some hospitals have equipment that gives breathing support without having to cut the cord.

But if your baby needs more help, your healthcare team may need to cut the cord straightaway.

Can I have delayed (or optimal) cord clamping with a caesarean section?

You can still have delayed cord clamping if you have a caesarean section, whether it is planned or an emergency.

Usually, the placenta will be taken out at the same time as your baby. Your healthcare professional will then wait to cut the cord (or for your birth partner to cut the cord, if that’s what you want) before cleaning and checking your baby’s health, and passing them to you for a cuddle.

You can talk to the health professionals caring for you about this.

Should I have delayed (or optimal) cord clamping on my birth plan?

Yes. It may be helpful to talk to your midwife or doctor about delayed cord clamping during your pregnancy. You can then add your preferences to your birth plan.

If you have a birth partner, talk to them about what you’d like to happen so they are also aware.

But try to remember that labour does not always go to plan. You may need to be flexible and prepared to do things differently.

What is the difference between delayed (or optimal) cord clamping and milking the cord ?

Delayed cord clamping is a natural process where the cord blood is transferred to the baby with no help from health professionals.

But milking the cord is when the midwife or doctor push the blood through the cord, so it is transferred more quickly. It is a safe technique, but it usually only happens if the process needs to happen more quickly. This is usually because the baby needs help with their breathing.

Milking the cord may also be a better option for babies born before 28 weeks of pregnancy.

Can delayed (or optimal) cord clamping cause increased levels of jaundice in the first week of birth?

There is a small increased risk of jaundice in babies who have received deferred cord clamping, but this is usually mild.

Jaundice is very common in newborn babies and it may happen no matter how soon the cord is clamped after birth.
Your baby will be examined for signs of jaundice within 72 hours of being born as part of their newborn physical examination.

Can I still preserve blood from the cord for medical research?

Umbilical cord blood can be used to treat and cure many life-threatening diseases.

Some parents want their cord blood to be collected at the time of birth and stored, so that it is available for medical research.

Banks can still collect high-quality units of cord blood following delayed cord clamping. But it is important that the cord blood is drained as soon as possible following delayed clamping to maximise the potential volume.

Your midwife or hospital maternity unit may have more information about cord blood banking. You can also find out more from the Human Tissue Authority.

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Improve fetal position - Spinning Babies

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Improve fetal position - Spinning Babies

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The Fantastic Four are:

Enjoy regularly in pregnancy and try in labor for comfort and or progress. Learn all of these by watching Gail teach them to pregnant parents in the Spinning Babies Parent Class video:

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The Fantastic Four are: Enjoy regularly in pregnancy and try in labor for comfort and or progress. Learn all of these by watching Gail teach them to pregnant parents in the Spinning Babies Parent Class video: