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

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When you're waiting for things to start...

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When you're waiting for things to start...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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The place of in between - Zwischen | Nest & Nurture

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

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a video

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Microbiome: First bacteria we meet can keep us out of hospital

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For the first time, scientists show how our microbiome forms affects the risk of infection.

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"Empathy, Expertise & Support"

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This Padlet is for use alongside NCT Parent Hub.

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one to read in advance, not on the day!

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Author: Debs Neiger Independent Midwife

This is the big question for many. Most women find it hard to imagine that their vagina/perineum/vulva will stretch enough to accommodate a WHOLE human baby during the expulsive stage of labour (also called second stage) without major trauma. Even if they have had a baby before, the thought of that last stretch before holding the baby is daunting.

For many it feels like that there is nothing they can do other than grit their teeth and hope for the best.

So, what if I told you there ARE things that you can do to protect your perineum from damage? You might even be surprised to hear that LESS IS MORE. Less intervention, less worry, less outside input into how you bring your baby into the world make for less perineal trauma. But what does this mean? Isn't it best to listen to what your midwife instructs you to do when birthing a baby? Don't they know best?

In general terms it means that your body is perfectly designed for birth. It means that your mind and your body are made to work together perfectly to birth a baby. Hormones in your body during pregnancy and birth make your perineal tissues more pliable and stretchy. Outside interference CAN sometimes be helpful, such as good communication, if you would like some more support during the very last moments of birthing your baby's head......but mostly, your own body is excellent and capable at giving you reliable signals as to how to birth your baby.

Does this mean that you will birth easily, and your perineum will stay intact IF you simply do everything 'right'? No. It simply means that you are likely to give yourself the best chance at a normal physiological birth with minimal damage if you respect your own birth physiology.
How the perineum feels during birth
When you reach the last stage of labour, the one I like to call the expulsive stage (many other midwives will call it the second stage of labour/being fully dilated) your baby has descended through the pelvis far enough to trigger a feeling of 'expulsiveness'. This feels different for everyone. For some women, it is simply an overwhelming sense of fullness and pressure, often on their back passage more than the vagina, almost like needing the most enormous poo ever. For some, it is an urge to bear down, almost automatic, like their body is telling them in no uncertain terms to push out a baby. And for many, possibly most, it is a completely involuntary bearing down, sometimes quite overwhelming and forceful with no ability to stop it. All of those sensations are normal.

This expulsive stage will lead to the baby moving through the pelvis, the perineum stretching and expanding, often giving you an intense stinging or burning sensation and eventually letting the baby's head birth, and after that the shoulders and the rest of the baby's body. Keeping the perineum as relaxed, and the birthing position as conducive to the perineum stretching as possible, go a long way in promoting a healthy birth.
What does the research say?:

A mobile birthing person who is able to choose their birthing position, then navigates the expulsive phase of birth in the way that feel best to them, can reduce perineal damage.

All fours, kneeling and side lying positions seem to result in less perineal trauma, whereas laying on ones back, lithotomy (legs in stirrups), birth stools and deep squatting may result in more severe tearing.

A slow, controlled birth of the head is likely to lead to less perineal damage.

Good trusting and established communication between mother and midwife can enable a slow and gentle birth.

A warm compress can reduce the chances of more severe perineal tearing.

There is no good research to show that the midwife using her hands to put pressure on the perineum leads to less perineal trauma in a normal physiological birth.

Waterbirth may be protective for the perineum.

Coached pushing- being told to hold your breath and 'push as hard as you can into your bottom'- is more likely to lead to perineal damage and can contribute to less oxygen reaching your baby.

An induction makes perineal damage more likely.

An instrumental birth such as forceps or ventouse makes perineal damage more likely.

An epidural makes tearing more likely.

So, how can you do this during your labour?

Ensure you are as mobile and as able to adopt the most comfortable positions for yourself as possible.

Follow your body's cues. You might find yourself getting into weird and wonderful positions you didn't think would work for you, but oddly they are the only thing that feels 'right' at the time (hanging from door handles/sitting on the toilet/floating almost face down in the pool/wedged in the minute space between bed and wall spring to mind).

Both of the above are very possible even with an epidural or monitoring leads or drips in place. Creativity (peanut ball/inventive use of cushions/adaptable birthing furniture) and willingness from HCPs (encouragement to support physiology/assisting with positioning/reorganising wires and tubes).

Labour and birth in the water.

Let the sensations of the expulsive stage of labour be and work with them to birth your baby. Avoid the 'traditional coached pushing' some midwives might want to instruct you to do......we know that this has several downsides including less oxygen travelling to the baby, as well as increased perineal damage.

If your body makes you push, go with it.

If your body lets you breathe while your uterus is pushing the baby down, go with that.

If your body is telling you to take short panting breaths as the baby's head is being born, do that.

Perhaps put your hand over your expanding vulva and feel your baby's head being born. This might enable you to slow the last bit of expulsion and minimise any trauma.....it can also feel AMAZING to be the first person to touch the baby and guide them into the world.

Ask your care provider to offer you a warm perineal compress as the baby's head is starting to stretch the perineum. To many women this feels amazing and can protect against more severe tearing.

If you are quite immobile and have a loss of sensation that leaves you unable to follow your body's signals, DO discuss the desire for a slow and gentle birth of the head with your midwife. Good communication and, for example, a perineal compress are still very much achievable, even if you can't feel much. You can also still use your own hands to feel how quickly or gently your baby is being born and adjust your efforts to slow the birth.

Proactively seek a model of care that can ensure that you have a *known to you* midwife with you for birth. Many NHS trusts are working towards this type of continuity of carer which provides many benefits for birthing people and their babies. Independent midwives always provide this. It provides trusting communication and promotes safety during birth.

Hopefully, this gives you plenty of ideas for a perineum friendly birth. It is also worth remembering that often, some perineal damage is inevitable, a normal part of the birth process and very much something you can recover from well and easily.

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How to protect your perineum during birth

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Author: Debs Neiger Independent Midwife This is the big question for many. Most women find it hard to imagine that their vagina/perineum/vulva will stretch enough to accommodate a WHOLE human baby during the expulsive stage of labour (also called second stage) without major trauma.

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midwife gently explains the process & rationale

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Harrogate and District NHS Foundation Trust

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Caesarean Birth: who will be in theatre?

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Caesarean Birth: who will be in theatre?

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You may be surprised by how crowded the theatre can get during a caesarean. There will be doctors, midwives and nurses present. Each is there to care for you and your baby at different stages of the operation and the recovery to follow.

The following people are likely to be present:

a midwife, to do basic checks on your baby once he's born

a consultant obstetrician or registrar, who does the surgery

the obstetrician's assistant

an anaesthetist, who gives you the drugs to numb you

a paediatrician, if you are under general anaesthetic, or if your baby will need special care once he's born

a paediatric resuscitation team, in case your baby needs help straight away

an anaesthetic nurse or operating department assistant

a scrub nurse, to help the obstetrician with the instruments

one or two theatre nurses

medical students or student midwives (with your permission)

The total number of people with you in the theatre depends on the type of birth you are expected to have. If you're giving birth to one baby, and it's likely to be straightforward, there may be nine or 10 people. If you're having twins, and there are concerns for you and your babies' wellbeing, the number will be higher. There could be as many as 20 people in theatre with you.
Your birth partner should be allowed in theatre too, as long as you're not having a general anaesthetic. Having a familiar face will probably be a great comfort in such a clinical place.

However, the caesarean may not feel like a very private moment for you and your partner. You may feel as though you lack control, although you can still make choices:

You can ask for anyone who doesn't need to be there to leave. This may mean just the students, as everyone else there should have a role in the birth. Though students need to see caesareans as part of their training, it doesn't have to be your caesarean.

During your baby's birth, you can ask for quiet, so that you don't miss out on hearing your baby's first cry. It may be possible for yours to be the first voice your baby hears, though this depends on your individual circumstances. Discuss this with the midwife looking after you.

You can ask that your partner is the one to tell you the sex of your baby.

You can request your favourite music to be played whilst your baby is being born.

If you're having an emergency caesarean, things tend to move more swiftly, but that doesn't mean you can't make requests. If there is time, your operating team should be able to accommodate your wishes.
To plan the birth experience you want for your caesarean, see our guide to writing a caesarean birth plan.

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Who will be in the operating theatre during my caesarean?

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When you go into theatre for your caesarean, it may come as a surprise how many people are needed to do the operation. Find out who needs to be there and why.

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A relaxation for when you're feeling stressed

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A relaxation for when you're feeling stressed

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Guided Relaxation Hannah Appelgren by Hannah Appelgren

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A short guided relaxation to help you feel calm, suitable for anyone feeling a little anxious, tense or worried right now

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CW: shows birth during surgery

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The natural caesarean - a woman centred technique

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NHS promises about your care

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Personalised Care and Support Planning in Maternity Services

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shorter read

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longer read

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Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions. The term 'augmentation' is often used instead of 'induction' for this procedure. Women who choose to wait are usually told their baby is at increased risk of infection and they are encouraged to have IV antibiotics during labour.

The rush to start labour and get the baby out after the waters have broken is fairly new. When I first qualified in 2001 the standard hospital advice (UK) for a woman who rang to tell us her waters had broken (and all else was well) was: "If you're not in labour by [day of the week in 3 days time] ring us back." Over the following years this reduced from 72 hours to 48 hours, then 24 hours, then 18 hours, then 12 hours and now 0 hours. You might assume that this change in approach was based on some new evidence about the dangers involved in waiting for labour. You would be wrong.

This post is mostly based on a couple of Cochrane Reviews because hospitals are supposed to base their policies/guidelines on research evidence. Obstetricians also tend to have great respect for research evidence - certainly more than other forms of knowledge midwives also use (experience, intuition, witchcraft etc.). However, please note that research reviews are only as good as the research reviewed. Research is not conducted in a vacuum, and the questions that are asked, and the methods used, tell us a lot about the social and cultural context of knowledge, and what is valued. For example in most trials the 'doing nothing' group is the experimental group and the 'routine intervention that was previously introduced without evidence' is the control group. You can read more about research bias in maternity care in this post.

Please note that this post is not about premature rupture of membranes (before 37 weeks)

The outcomes: induction vs waiting

A Cochrane Review comparing planned (induced labour) vs expectant (waiting) management concluded that neonatal infection 'may be' reduced. Unfortunately, the research reviewed was not great: "Only three trials were at overall low risk of bias, and the evidence in the review was very low to moderate quality." Indeed all of the evidence in the review was rated 'low quality' except the evidence demonstrating no difference in the rate of death for babies between inducing vs waiting (this was the only 'moderate quality' research).

Whilst the review reports a slight increase (less than 2%) in 'definite or probable' neonatal sepsis, this needs to be unpicked a little. Once the 'probable' portion was removed in the analysis the difference was no longer significant. It would be very interesting to know how many of the suspected (probable) cases of sepsis were merely care providers being cautious and making assumptions. For example, some symptoms associated with sepsis can be caused by other interventions - epidural increases the chance of a high temperature in both mother and baby; and a stressful labour (and syntocinon) can result in low blood glucose in the newborn. It is common practice to assume infection until proven otherwise and treat accordingly. The fact that there was no difference in Apgar scores between the groups increases my suspicions in this area. Infected babies are much more likely to have a poor Apgar score and require resuscitation at birth.

The review goes on to state that: "...evidence about longer-term effects on children is needed." And there is increasing evidence about the risks of the induction process for babies that needs to be considered by women when making a decision.

The Cochrane review did find a slight increase (1%) in the absolute risk of uterine infection for mothers who waited for labour. Bear in mind that these studies were done in hospitals which are not the best setting when attempting to avoid infection. If a uterine infection is identified early it can usually be effectively treated with antibiotics. I used to see quite a few uterine infections as a community midwife in the UK doing postnatal home visits - mostly after forceps or ventouse births. However, if the symptoms are missed, or the woman does not have access to antibiotics; or the infection is antibiotic resistant, a uterine infection can be life-threatening.

The report found no difference in the rate of caesarean sections. However, the stats for first-time mothers are not separated out. This is frustrating because induction increases the chance of caesarean significantly for first time mothers (see this post). Women who have previously given birth have no increased chance of caesarean with induction. When you mix the two groups together (like most research does) you miss the outcomes for those first-timers. Interesting only two of the studies in the review looked a uterine rupture during induction - a greater risk for women who have previously laboured.

The experience: induction vs waiting

Only one of the trials in the Cochrane Review bothered to ask women what they thought of their experience (no surprises there). In this trial, women who had their labour augmented were more likely to tick the box saying that there was 'nothing they disliked in their management'. There are huge limitations when using surveys to assess experiences, and a good qualitative study is needed here. For example, how can a woman compare one experience (induction) against an experience they did not have (physiological labour) - you don't know what you don't know. Also, if a woman believes she is protecting her baby against infection by inducing labour this may influence her perception of the management. The Cochrane Review states that no trials reported on maternal views of care, or postnatal depression.

Antibiotics - just in case?

A Cochrane Review of antibiotics for pre-labour rupture of membranes at or near term concluded that: "There is not enough information in this to assess the possible side-effects from the use of antibiotics for women or their infants, particularly for any possible long-term harms. Because we do not know enough about side-effects and because we did not find strong evidence of benefit from antibiotics, they should not be routinely used for pregnant women with ruptured membranes prior to labour at term, unless a woman shows signs of infection."

The National Institute for Clinical Excellence (UK) guideline states "If there are no signs of infection, antibiotics should not be given to either the woman or the baby, even if the membranes have been ruptured for over 24 hours."

So it appears that women and babies are being given high doses of antibiotics during labour without sufficient evidence to support the practice. In addition, these antibiotics may have short term, and long term side effects. As a student midwife I was asked by a mother what would happen if her unborn baby was allergic to antibiotics. I had no idea and asked the Consultant... after a long and complex answer I realised he didn't know either. I am guessing that most side-effects are more subtle than anaphylaxis. The effect I most often see is oral thrush in the baby and co-existing nipple thrush - and subsequent breastfeeding problems. However, more worrying are the potential long term problems associated with antibiotic exposure - most likely due to the disruption of gut microbiota and the integrity of the immune system. Another issue is the development of antibiotic resistant bacteria due to the overuse of antibiotics, which can result in infections (e.g. uterine) being difficult to treat.

Choosing to wait

Women need to be given adequate information so that they can make the decision that is right for them. I'm not sure most women are fully informed, and instead are told their baby is 'at risk'. As we know, you can get a mother to do anything if she believes it is in the best interests of her baby. So what happens if a woman chooses to wait for labour?

Most women (79%) will go into labour within 12 hours of their waters breaking and 95% will be in spontaneous labour within 24 hours ( Middleton et al. 2017). Ashlee whose birth I recently attended has given me permission to share her experience and photos here. Ashlee's daughter Arden taught both her family and her midwives about patience and trust. We waited 63 hours from waters breaking to welcome her into the world. After a 2 hour, 20 minute labour she was gently born through water and into her mothers arms (notice the nuchal cord). I wonder how different this birth would have been if Ashlee had chosen to follow hospital guidelines. Instead she weighed up the information for herself and chose to stay home amongst her own familiar bacteria, and let her daughter decide when she was ready to be born.
Suggestions for waiting:

View the situation positively - we are all getting time to prepare for the birth and the arrival of baby. She can use the time to relax, sleep and be pampered.

The vagina self cleans downwards. Reduce the chance of infection by not putting anything into the vagina ie. no vaginal examinations. If a vaginal examination is absolutely necessary sterile gloves must be used.

Some women like to boost their immune system with nutritional supplements (eg. vitamin C, echinacea, garlic).

Be self-aware, connect with your baby and let your midwife/care provider know of any changes eg. feeling unwell, a high temperature, if the amniotic fluid changes colour or smell, any reduction in the baby's movements etc.

I have observed Acupuncture and Bowen Therapy encourage contractions. However, if the cervix is not ready the contractions will fizzle out. If the cervix is ready, it may be enough to kick start labour. Nipple stimulation will also stimulate oxytocin (and clitoral stimulation will too).

Most importantly trust the process. Birth will happen.

Once the baby is born - keep baby skin-to-skin with mother to reduce the chance of infection by allowing the baby to become colonized by his mother's bacteria (this applies to all births).

After birth be aware of signs of infection. Mother: fever, raised pulse, feeling unwell, smelly vaginal discharge, uterine pain. Baby: fever, noisy breathing, change in colour (pale), listless.

Summary

The research evidence regarding induction for rupture of membranes is poor. Giving antibiotics in labour 'just in case' is not supported by current evidence, and may cause problems for baby and mother. Women need adequate information on which to base their decisions regarding the management, or not, of this situation. Women who choose to wait for labour should be supported and to do so.
You can read more about induction in my book Why Induction Matters

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Pre-labour Rupture of Membranes: impatience and risk

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Updated: July 2019 Amniotic sac and fluid play an important role in the labour process and usually remain intact until the end of labour. However, around 10% of women will experience their waters breaking before labour begins. The standard approach to this situation is to induce labour by using prostaglandins and/or syntocinon (aka pitocin) to stimulate contractions.

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From 'after pains' to six weeks of bleeding, what happens after birth is rarely discussed.

Earlier this week we spoke to an obstetrician who answered some of the biggest questions we had about what happens to the female body after childbirth. A number of mothers got in touch afterwards to dispute the advice and claim what actually happens had been played down.

Milli Hill, the author of The Positive Birth Book, founder of the Positive Birth Movement - a network of antenatal discussion groups - and a mum of three shared her thoughts and experiences on the realities of a woman's life post- childbirth with The Independent.

The physical symptoms

I think this depends hugely on what kind of birth experience you had and how you are feeling about it. By that I don't necessarily mean whether you had a straightforward vaginal birth or caesarean, because some women who had a caesarean may feel very sore and debilitated whilst others will recover more quickly. Often, in my experience, it is the way a woman feels about the birth emotionally that has a huge impact on her physical recovery, as well as the actual nature of the birth itself. So a woman who had a straightforward birth but did not feel listened to or respected during her labour may recover more slowly than a woman who had a gentle caesarean in which she felt in control of events and well cared for.

After birth, there are sometimes 'after pains' for a few hours or even a day or two - no one warns you about these but after my second baby (they are most common after second or subsequent babies), I was mightily annoyed that after all of the hard work of labour was over, I continued to experience pain that felt like contractions, for about 24 hours.

Aside from this, I think we need to take care talking about birth in terms of 'symptoms'. Birth is an expression of a woman's body in the absolute peak of health, and in the majority of cases, it does not need to be a medical event. If you have had a positive birth and you are feeling good about it, then you will often feel completely energised and brilliant in the days after you have had your baby. Women need to hear this message too as well as getting information about what might be unpleasant or what might go wrong.

Bleeding

After you have had your baby - regardless of whether you have had a vaginal birth or a caesarean - you will have something that resembles a very heavy period, called Lochia. This can be very heavy in the first few days and you will need to use 'maternity pads' (never tampons as this can introduce infection). The pads are just like very thick sanitary towels built for a very heavy flow. Lochia will be bright red initially, and after the first few days it will become lighter in flow and may change to brownish red, but you can expect it to continue for at least two weeks and up to six weeks after the birth.

The effects on the mind

Having a baby brings a huge period of readjustment, your life is literally transformed overnight. For many, it is a time of great happiness and fulfilment but, like every other time in life, it is unrealistic to expect everything to be a bed of roses. Unfortunately, we do not have much support for new mothers in our current society and, once the visits from family and friends are over, it can be a very isolating time - one mother described it to me as 'solitary confinement'. After my first baby I certainly felt a bit like this - alone in my house with my baby it felt like everyone I knew was at work and I wasn't really sure what to do with myself. I think women literally have to start again sometimes, making new friends and a new routine to their day and this can be really tough, especially when you are sleep deprived. I think that this social set-up where women are so isolated and unsupported, where they feel overwhelmed with emotions for their baby, and where they feel they have lost much of their former identity, can be as much if not more of a contributor to postnatal depression as 'hormones'. It would be great if there were more support for mothers and more awareness around postnatal mental health - this is something that as a society we really need to be working towards.

Pain

There can be pain and discomfort for some women depending on what kind of birth they had and how they are feeling about the birth, what level of support they are getting etc. If you have had an instrumental delivery, a difficult birth or a caesarean, then you will feel in pain or discomfort for days or even weeks. But any severe pain should be reported immediately to your midwife or doctor as it could be sign that something is wrong. If you've had a straightforward birth you might be feeling a bit tender but I don't think it's normal to feel in pain. However, everyone is different. Some people may run a marathon and feel fantastic afterwards, others may take longer to recover.

I like what renowned American midwife Ina May Gaskin has to say - she points out that she reminds us that labour pain is 'clean'; when it's over, it's over, and it almost always causes no damage to the body. The paradox as she puts it is this: 'When avoidance of pain becomes the major emphasis of childbirth care... most women have to deal with the pain after their babies are born'. In other words, labour pain may be tough, but recovery from instrumental or caesarean deliveries (which are more likely to happen if you opt for an epidural) can often be even tougher.

The vagina

I think for most women (I'm talking about those who have had a straightforward birth here) their vulva and vagina will look and feel a bit different after birth, but with time and a few 'pelvic floor exercises' it will go back to being fairly similar to before. Many women will have a small tear after the birth - this sounds utterly terrifying but in the majority of cases you won't notice it happening and it will heal well and easily. Severe tears called third or fourth degree tears are another matter and will take longer to heal and will require specialist care - but these are extremely rare, happening in only five per cent of cases for first time mothers and two per cent for those who have had a previous baby. Episiotomies - when a cut is made to the perineum to help the baby out - can also be painful and take time to heal.

The way your body changes

I think it would be very odd if your body didn't change, although, unfortunately, that is our cultural aspiration and expectation. We see celebrity mums on the red carpet, getting praise piled on them for 'getting their body back' after 'only two months!' and there we are, at home, in our sick splattered pyjamas - it can make us feel like utter failures! Again, everyone is different - but I think the reality for most women is that their body is changed, perhaps in a small way, perhaps in a big way - but either way it is changed. Because of the cultural expectation to look 'like you never had a baby', many women have negative feelings about their post-baby bodies, which is a shame, as really we ought to be proud of the amazing achievement of growing and nurturing another human, don't you think?!

Sex life

This is completely up to the individual. For most new parents sex is pretty low down the list as they have got a tiny, utterly dependent human being to look after 24 hours a day, seven days a week. The baby is usually 'on you' a lot of the time, sleeping, feeding etc, and if they finally do nod off in the moses basket, it's more likely you'll want to crash out than initiate sex. The standard advice is to wait until your post birth bleeding has stopped so around 3 to 6 weeks, but many wait much longer due to a traumatic birth or simply the demands of parenting and part of the development of your relationship with your partner as a 'three' rather than as a couple will probably involve discussing this and navigating your individual needs.

The afterbirth

[The afterbirth] is much easier than having a baby. The placenta is quite soft and squishy and usually comes out fairly easily, perhaps with just gently pushes if you are having a physiological third stage (when you deliver the placenta naturally and don't have drugs to make it come out). I actually found it a really satisfying feeling. Sink back and revel in the moment. And have tea and toast.

Help and support

I think midwives work hard to make sure that women get the information they need but it's always a good idea to do your own reading about what to expect. There are lots of great books, websites and social media forums where you can learn more about the finer details. I personally think that talking to other women and hearing about their experiences is hugely helpful, which is why I started the Positive Birth Movement.

Reuse content

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Mother reveals the reality of what happens to your body after giving birth that doctors rarely discuss

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From 'after pains' to six weeks of bleeding, what happens after birth is rarely discussed. Earlier this week we spoke to an obstetrician who answered some of the biggest questions we had about what happens to the female body after childbirth.

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offered to all babies at birth

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Vitamin K and newborns: what you need to know | Labour & birth articles & support | NCT

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If you’ve heard people talk about Vitamin K but are feeling a bit clueless, here’s the information you’ll need.

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A simple heat pack can reduce pain and perineal tearing during childbirth. Shutterstock/Uber Images

A common fear women have when contemplating having a baby is whether the birth will tear the tissues between the vagina and anus, also known as the perineum. How can something as big as a 3.5kg baby come out of something as small as a vagina without inflicting damage?

Fortunately, the vagina is designed to accommodate a baby. Hormones flood a woman's body during pregnancy and labour, increasing blood supply and changing the stretchiness of tissues in that area.

Evidence shows appropriate use of heat packs along with other aspects of clinical care can improve comfort during the final minutes of giving birth, and reduce the risk of tearing in the perineum.

How common is tearing during childbirth?

Only 2% of women endure the most severe form of perineal tearing during birth, involving the vagina, perineum and sometimes the anus. Around 27% of women experience no tearing at all, while 23% have a very minor vaginal tear or graze that often does not require stitches and heals on its own. Around 26% of women have a perineal tear that may need to be stitched.

A surgical cut to the perineum called an episiotomy is performed on around 20% of Australian women during childbirth.

The rate of perineal damage during childbirth has increased over the past 100-200 years. While a quarter of women are tear-free during birth in Australia today, some data suggests 95% of women had no tearing in the 1800s.

Some reasons for this discrepancy may include 19th century women being younger at time of delivery, having many babies close together, birth taking place in an upright position and less medical intervention such as forceps, vacuum and episiotomy during delivery.

From 'old wives tales' to evidence-based care

Hannah's interest in perineal care started when she was a student midwife in the UK. She witnessed a labouring woman who, although close to giving birth, seemed scared of letting her baby emerge. The supervising midwife - an older woman, and very experienced - quietly got up and left the room, and returned a few minutes later with a bowl of steaming water. She proceeded to put a cloth in the water, wring it out, and place it gently on the woman's perineum.

The woman's face relaxed noticeably, and she gave birth to her baby. When questioned about what was in the water, the senior midwife answered, "just soothing the ring of fire ducky" (taking the stinging out of the birth).

nurmi/flickr, CC BY-NC-ND

Hannah went on to undertake the largest randomised controlled trial - now known as the warm pack trial - examining whether placement of a warm pack on a woman's perineum reduces perineal tearing and improves comfort.

A warm pack consists quite simply of a sterile pad soaked in very warm water (300mls boiling and 300mls cold tap water) and wrung out.

The results showed that warm packs reduce the most severe perineal tearing, as well as lowering women's pain during the birth and the first couple of days afterwards.

The study also found urinary incontinence was reduced three months following the birth.

Perineal warm packs are now accepted as an approved technique for use during childbirth thanks to a validated review of approaches to reduce perineal tearing. The report concludes the use of perineal warm packs is associated with decreased occurrence of perineal trauma and is acceptable to both women and midwives.

Compassion matters during childbirth

Research led by Holly has examined the experiences of women who have endured the most severe form of perineal trauma. Women were able to clearly describe the way they were treated by health professionals throughout their labour, birth and postnatal period. This treatment experience shaped their recovery in both negative and positive ways.

Many of the women reported feeling they were not well supported, they were dismissed and disregarded, and at times they were treated "like a piece of meat".

We found relationships with health providers and compassionate care were key in how women perceived the experience of sustaining a severe perineal tear. The women who felt the most supported throughout their experience were those who had received continuity of care by a known care provider (midwife or obstetrician).

They were more likely to be linked into services to give them support, and more likely to seek support themselves as they had been told what was normal and not normal when it came to post birth symptoms.

When asked what women considered to be ideal and most helpful, they identified information, continuity of care, compassion, understanding and support as critical. Compassionate, empathetic care should be provided to all women who are having a baby as a fundamental human right.

Factors contributing to the risk of perineal trauma

A number of factors influence the likelihood of perineal trauma associated with tearing or as a result of episiotomy:

Perineal trauma is more likely:

Perineal trauma is less likely when:

Midwifery has a history of using warmth applied to the perineum as a source of comfort in labour and childbirth. Modern evidence now supports the use of warm packs along with other aspects of care to reduce perineal tearing, to lower pain and to improve physical and mental recovery after giving birth.

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What we know about perineal tearing, and how to reduce it during childbirth

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A common fear women have when contemplating having a baby is whether the birth will tear the tissues between the vagina and anus, also known as the perineum. How can something as big as a 3.5kg baby come out of something as small as a vagina without inflicting damage?

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

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post-surgery advice

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When meconium is noticed in amniotic fluid during labour it often initiates a cascade of intervention. A CTG machine will often be strapped onto the woman reducing her ability to move, labour in water, and increasing her chance of having a c-section or instrumental delivery ( Alfirevic et al. 2013). Time limits for labour may be tightened up further resulting in induction or augmentation, which increases the chance of fetal distress and for first time mothers, c-section. As the baby is being born he may be subjected to airway suctioning which can cause a vagal response (heart rate deceleration) and difficulties with breastfeeding. Once born, the baby is likely to have his umbilical cord cut prematurely and be given to a paediatrician who may also suction the baby's airways. In the first 24 hours after birth the baby will be disturbed regularly to have his temperature, breathing and heart rate assessed. In some hospitals the baby will be taken away from his mother to be observed in a nursery.

This is a lot of fuss for a bit of poo which in the vast majority of cases is not a problem. Indeed many of the interventions implemented because of the meconium are more likely cause complications than the meconium itself.

This post is mostly based on two journal articles. One by obstetricians in an obstetric journal ( Unsworth & Vause 2010) and the other by a midwife in a midwifery journal ( Powell 2013). Both agree that there is very little known about meconium and whether it is a problem at all.
Meconium facts
Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.). Around 15-20% of babies are born with meconium stained liquor.

There are three reasons (theoretically) that a baby will open his/her bowels before birth ( Unsworth & Vause 2010):

1. Because their digestive system has reached maturity and the intestine has begun working ie. moving the meconium out. This is the most common reason - 15-20% of term babies and 30-40% of post-term babies will have passed meconium in-utero.

2. Because their cord or head is being compressed (during labour) ie. a vagally mediated gastrointestinal peristalsis - the same reflex which causes variable heart rate decelerations. This is a normal physiological response and can happen without fetal distress. This may be why a lot of babies pass meconium as their head is compressed during the last minutes of birth and then arrive with a trail of poo behind them.

3. Fetal distress resulting in hypoxia. However the exact relationship between fetal distress and meconium stained liquor is uncertain. The theory is that intestinal ischaemia (lack of oxygen) relaxes the anal sphincter and increases gastrointestinal peristalsis = passage of meconium. However, fetal distress can be present without meconium, and meconium can be present without fetal distress.

Bear in mind these are theories and there is no evidence to support them. Indeed in 'animal models' the theory that hypoxia results in meconium has found to be incorrect. There are also other theories about meconium in pregnancy - that the baby continually passes it - but I think this post is confusing enough with wading into them (see the key articles for further information).

Meconium alone cannot be relied on as an indication of fetal distress: "... meconium passage, in the absence of other signs of fetal distress, is not a sign of hypoxia..."( Unsworth & Vause 2010). An abnormal heart rate is a better predictor of fetal distress; and an abnormal heart rate + meconium may provide an even better indication that a baby may be in trouble. In addition, thick meconium rather than thin meconium is associated with complications. In summary, it is important to remember that:

Most babies who are born in a poor condition do not have meconium stained liquor

Most babies with meconium stained liquor are born in good condition

Despite this, babies who are known to have passed meconium (of any variety) without any other risk factors are treated as if they are in imminent danger. I am guessing this is because if a previously unstressed baby becomes hypoxic during labour it may result in the dreaded MAS.
Meconium Aspiration Syndrome (MAS)
MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication - around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS ( Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s - basically it is very rare but can be fatal. For those who like numbers if you have meconium in your amniotic fluid your baby has a 0.06% (1:1667) chance of dying from MAS. This risk will go up and down depending on individual circumstances eg. prematurity, additional labour complications, etc.

MAS occurs when the baby inhales meconium stained liquor during labour, birth or immediately following birth. Babies make shallow breathing movements during pregnancy. Breathing movements slow down in response to prostaglandins before birth. In order for a baby to gasp in-utero he must be extremely asphyxiated and have gone through a number of stages. This is unlikely to happen without anyone noticing the baby is in trouble ie. an abnormal fetal heart rate during auscultation and an abnormal labour (or induced contractions). A baby is able to maintain aerobic metabolism until oxygen levels at the 'placental blood exchange site' drop 50% below normal levels. The baby then undergoes a number of physiological compensatory responses and if the oxygen level does not improve, or worsens he will descend through hypoxaemia, hypoxia, anaerobic metabolism, metabolic acidosis, asphyxia, and then become 'unconscious' at which point his limbic system will initiate a gasp in an attempt to get oxygen.

Meconium in the lungs can cause problems with respiration and increase the risk of infection. For 3-5% of these babies it can result in death... but remember there are often other issues occurring along with the MAS eg. prematurity.

So, meconium alone is not a problem. Meconium + an asphyxiated baby = the possibility of MAS
Bizarre Practice
So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in asphyxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:

Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is 'slow' in an attempt to get the baby out of the uterus quickly.

Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.

Creating concern and stress in the mother which can reduce the blood flow to the placenta.

Directed pushing to speed up the birth.

Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.

Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.

Suctioning the baby's airways?
I am unsure whether this is common practice or not. Evidence based clinical guidelines generally recommend NOT suctioning a baby's airways unless they are unresponsive, floppy and require resuscitation. And then only to do so using a laryngoscope so that you can see what you are doing. Guidelines: NICE guideline, Resuscitation Council UK, more guidelines. Key research: Wiswell et al. 2000, Vain et al. 2004. So, I would assume that practice would be informed by this research and guidelines.

However, on my frequent youtube birth-surfing trips I encounter suctioning of babies often (without meconium present). Both 'on the perineum' and following birth. I have seen this being done at hospital births, homebirths, and even unassisted births. You can see an extreme version of suctioning in this previous post. A more conservative method using the suction bulb pictured above seems to figure in a lot of the homebirths on youtube. So, I am guessing that this is a common routine practice in the US. Therefore, I feel obliged to reiterate why this is not only invasive and pointless but may also be detrimental. Suctioning at birth does not reduce the risk of MAS but can:

In addition I am guessing it is not a very pleasant experience/welcome for the baby. Anyway, the birth process takes care of the mucous and amniotic fluid (and meconium) in the baby's airways. As you can see from the photo below the airways clear as the head is born and while waiting for the next contraction - the chest is compressed, squeezing the fluid out and gravity helps it to drain. Babies born by c-section miss out on this and are more likely to end up with problems associated with fluid in the airways and stomach.
Suggestions
All babies deserve to have the least stressful arrival possible. It is even more important that a baby who has passed meconium does not become stressed during labour and birth because it could lead to MAS. The following suggestions apply to all births including when there is meconium stained liquor:

Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously (hopefully this will happen after much of the labour is complete). If there is meconium present it will remain well diluted and the amniotic fluid will protect the baby from compression during contractions.

Ensure that the mother knows meconium is a variation and not necessarily a complication... the practitioner needs to consider the holistic picture - a post dates baby with old meconium is very different to a 38 week baby with thick fresh meconium.

If this is a concerning scenario ie. not post dates and thick meconium... or fresh meconium occurring during labour then increased monitoring and/or medical intervention may be required.

Otherwise, create a relaxing birth environment.

Avoid any interventions that are associated with fetal distress - ARM, syntocinon/pitocin, directed pushing.

In hospital do not allow others into the room unless the mother wants them there. If there is a policy to have a paediatrician present they can wait outside the room to be called if needed.

To assist with airway clearing encourage a slow birth of the baby's head in a position that allows drainage of the airways (ie. mother not lying on her back). Do not pull the baby out - allow the mother and baby to wait for the next contraction whilst the airways clear themselves.

Once baby is born leave the umbilical cord intact until it has stopped pulsing to allow a gentle transition to breathing.

Keep baby skin to skin with mother following birth.

Encourage the mother to let you know if she is concerned about her baby in any way over the next 24 hours (eg. feeling hot, noisy breathing, etc.)

Summary
Meconium in itself is not dangerous unless it is inhaled by the baby. For some babies meconium is a sign of hypoxia and they are at risk of meconium aspiration - these babies need additional monitoring and perhaps medical intervention. For most babies ie. those who are post dates, meconium is a sign of a mature digestive system that has begun to function - in these cases the aim should be to avoid hypoxia during labour and therefore meconium aspiration.

You can listen to an interview/discussion I had with Pregnancy Birth and Beyond Radio about meconium.

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When meconium is noticed in amniotic fluid during labour it often initiates a cascade of intervention. A CTG machine will often be strapped onto the woman reducing her ability to move, labour in water, and increasing her chance of having a c-section or instrumental delivery (Alfirevic et al. 2013).

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(birth is shown briefly)

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Sara Wickham article

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Ten things I wish every woman knew about induction of labour - Dr Sara Wickham

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In modern Western culture, most women and families know about induction of labour before they even become pregnant. They know that it is suggested when it is felt that it would be safer for the baby to be born than to stay inside its mother.

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Studio Memoir for BabyCenter

What is induced labour?

Your labour is described as "induced" when it's started artificially. You'll be offered an induction of labour if your doctor thinks that it is safer for your baby to be born sooner rather than continuing with your pregnancy (NICE 2008a).

Though most labours begin naturally, and letting nature take its course is usually best, you may need a little help to get started.

Why might my labour need to be induced?

You're likely to be offered an induction if:

Your pregnancy has gone beyond 41 weeks (NICE 2008a), though the exact timing may depend on your hospital's policy. Being overdue is the most common reason for induction (NICE 2008b).

Your waters have broken, but labour hasn't started. If you don't go into labour within a day or so, there is an increased risk that you or your baby could develop an infection. So you'll be offered an induction about 24 hours after your waters break (NICE 2008a, NICE 2014).

You have diabetes, which means there's a small risk that your baby will be larger than normal. If you have type 1 or type 2 diabetes and your baby is growing as expected, your doctor will recommend you have an induction between 37 weeks and 38 weeks of pregnancy. If you have gestational diabetes and your pregnancy is going well, your doctor will advise induction no later than 41 weeks (NICE 2015a). If there are signs that your baby is big, your doctor may recommend a caesarean as the best option for you.

You have a chronic or acute condition, such as pre-eclampsia or kidney disease, that threatens your wellbeing, or the health of your baby (NICE 2019).

You are 40 years of age or older, which can carry a higher risk of stillbirth. Being induced at 39 weeks to 40 weeks of pregnancy may reduce the risk, particularly if you have other complications (RCOG 2013).

You may have your own reasons for wanting an induction. For example, you may be worried about pregnancy complications, or if you've previously had a baby who was stillborn. Or you may want your labour to be induced if your partner would otherwise miss the birth.
What your doctor and midwife advise will be based on your individual circumstances, as well as checks to see if your body is ready for labour (NICE 2008a,b).

There should be time to ask questions, and time to talk to your partner, so that you come to a decision that feels right for you (NICE 2008a). Induction interventions are "offered" to you, which means that you can refuse if you want to, and your midwife or doctor should respect your decision (NICE 2008a).

How will my labour be induced?

There are a few methods your midwife can use to try to get your labour started. They'll use a vaginal examination first, called the Bishop score, to assess how ready your cervix is for labour. Depending on your Bishop score, some induction methods may need to be repeated, or you may need to try more than one before your labour progresses well.

Here's the order in which you're likely to be offered particular methods of induction.

Membrane sweep

A membrane sweep is when a midwife or doctor sweeps their finger around the opening of your cervix. This can encourage labour to start. Your midwife may offer you a sweep if you're full term. They'll suggest a sweep at your 40-week appointment and again at 41 weeks if this is your first baby. If you've had a baby before, you should be offered a sweep at your 41-week appointment (NICE 2008a).

If your waters have broken but labour hasn't started, membrane sweeps are not recommended, as they can increase your risk of infection (NICE 2014).

The membranes are the sac that surrounds your baby and that holds the amniotic fluid in. During a sweep, your midwife tries to separate them from your cervix, to directly stimulate the production of prostaglandin, which may help to kick off contractions and labour. If your cervix is not dilated enough to do a sweep, your midwife may stretch or massage your cervix instead. This is why the procedure is sometimes called a stretch and sweep.

You may be offered several membrane sweeps before labour starts. It can be uncomfortable and even painful while you're having this done, and afterwards you may have some cramps and bleeding (Mozurkewich et al 2011, NCT 2018, NICE 2008b). If you are unclear about anything, ask your midwife to explain. If you decide against a membrane sweep, you can wait for labour to start naturally or use a more formal method of induction, if it's offered to you.
Prostaglandin
Prostaglandin is a hormone-like substance that causes your cervix to ripen, and which may stimulate contractions. Before using it, your baby's heartbeat needs to be continuously monitored for 30 minutes and your Bishop score assessed (NICE 2008a).

Your midwife will insert a tablet, pessary or gel containing prostaglandin into your vagina. The slow-release pessary, Propess, looks a bit like a tampon. If you're given Propess, you have to lie on your side for 30 minutes so the pessary has time to absorb moisture and swell (EMC 2018a) . You'll then be able to move about.

While you wait for prostaglandins to work you can usually go for a walk. Depending on why you're being induced, you may even be able to go home while you wait for your contractions to start (NICE 2008a). You'll need to be examined after six hours with a tablet or gel, or after 24 hours with a Propess pessary (NICE 2008b) unless your contractions start sooner.

Prostaglandins may make you feel feverish, nauseous, be sick or give you diarrhoea and they can make your vagina feel sore, although these side effects are less common with Propess (EMC 2018a,b,c).

If prostaglandins don't work at all, you may be offered induction again at a later date (NICE 2008a). If your doctor thinks that it may be safer for your baby to be born sooner, you may be offered a caesarean instead (NICE 2008a,b).

There's a very small risk that using vaginal prostaglandins may cause your womb (uterus) to become overstimulated (NICE 2008a). This means that you may develop very intense, frequent or long-lasting contractions, which could be stressful for your baby. This is known as hyperstimulation.

If your womb does start to hyperstimulate, you can be given medication to stop or slow down your contractions. As Propess is similar to a tampon, it can simply be pulled out by your midwife. This alone can help your womb to settle (NICE 2008a).

Balloon catheter or other mechanical methods

Depending on where you live in the UK, your midwife may offer to induce your labour by inserting a balloon catheter into your womb. A balloon catheter helps to open your cervix using gradual physical pressure. The catheter is inserted into your womb while deflated, then slowly inflated with a little saline solution (Ezakoff and Kilpatrick 2013). As the balloon fills, it puts pressure on your cervix and encourages it to dilate, stimulating your labour to start.

Sometimes the catheter has a second balloon which is inserted in your vagina and inflated in the same way, gently applying pressure on both sides of your cervix. If you've had a previous caesarean section, however, you won't be offered a double balloon catheter (NICE 2015b,c).

Balloon catheters are left in place, usually for up to about 12 hours, while you are monitored. If your labour starts, your waters break, or your baby shows signs of distress the device will be removed (NICE 2015b).

Having a balloon catheter inserted may be uncomfortable but it should not be painful (Ezakoff and Kilpatrick 2013). Most women give birth within 24 hours of having a balloon catheter inserted (NICE 2015b,c).

Other mechanical methods involve dilators that swell as they absorb cervical and other fluids, putting pressure on your cervix and encouraging it to open (de Vaan et al 2019, Ezakoff and Kilpatrick 2013).

These methods appear to work just as effectively as prostaglandins and carry a lower risk of over-stimulating your womb (de Vaan et al 2019, NICE 2015b,c).

If your labour does not start using a balloon catheter, your doctor may recommend that you move on to other methods of induction (NICE 2015b).

Artificial rupture of membranes (ARM)

Also called breaking the waters, ARM is used by your midwife or doctor to speed up your labour if it's not progressing. ARM is also occasionally used earlier as part of the induction process if you're having problems with the vaginal prostaglandins, such as very frequent or very long contractions (NICE 2008b).

Your midwife or doctor will make a small break in the membranes around your baby. They'll use either a long thin probe (amnihook) or a medical glove with a pricked end on one of the fingers (amnicot). It can be quite uncomfortable, so you may be offered gas and air to help you relax.

ARM is no longer recommended as a method of induction on its own as it doesn't always get labour started, and once your waters have been broken, your baby could be at risk of infection (NICE 2008a). If your midwife or doctor suspects an infection, you'll be given antibiotics.

Syntocinon

Syntocinon is a synthetic form of the hormone oxytocin, which your body releases to help labour progress. You'll only be offered Syntocinon if a membrane sweep or prostaglandin hasn't started your labour, or if you're having contractions but your labour isn't progressing.

You'll have Syntocinon through an intravenous drip. Once your contractions have begun, the rate of the drip can be adjusted. This allows contractions to happen often enough to make your cervix dilate, without becoming too powerful.

Syntocinon is started at a very low dose and increased gradually to prevent it from over-stimulating your womb or causing stress to your baby. Don't worry, your midwife will ensure that your baby is monitored continuously to make sure all is well (NICE 2014).

The contractions brought on by Syntocinon tend to be more intense than natural ones. So you should be offered an epidural for pain relief (NICE 2008a).

The risk of Syntocinon causing your womb to become overstimulated or hyperstimulated is low (NICE 2008a). If this does happen, and turning down or stopping Syntocinon isn't enough, you'll be given medication to slow your contractions.

How can I prepare for my induction?

You have a choice about whether or not to have an induction, and about which methods are used. Your midwife or doctor may suggest that one method is better than another, depending on how soft and ready for labour your cervix is.

There's some evidence that if your labour is induced, you may be slightly more likely to need instruments such as forceps or ventouse to help your baby to be born (Middleton et al 2018, NICE 2008a). However, if you are near to term, being induced should not increase your chance of needing a caesarean and may even make a caesarean less likely (Middleton et al 2018, NICE 2014, RCOG 2013, Thomas et al 2014).

Before you go into labour, you may want to consider what pain relief you may want if the induction works and makes your contractions very strong and difficult to cope with.

Find out more about how induced labour is different.

Last reviewed: March 2020

References

EMC. 2018a. Propess 10mg vaginal delivery system. Electronic Medicines Compendium. www.medicines.org.uk [Accessed January 2020]

EMC. 2018b. Prostin E2 vaginal tablets. Electronic Medicines Compendium. www.medicines.org.uk [Accessed January 2020]

EMC. 2018c. Prostin E2 vaginal gel 2mg. Electronic Medicines Compendium. www.medicines.org.uk [Accessed January 2020]

Esakoff TF, Kilpatrick SJ. 2013. The transcervical Foley balloon. Contemporary Ob/Gyn. www.contemporaryobgyn.net [Accessed January 2020]

Middleton P, Shepherd E, Crowther CA. 2018. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 5: CD004945. www.cochranelibrary.com [Accessed January 2020]

Mozurkewich EL, Chilimigras JL, Berman DR et al. 2011. Methods of induction of labour: a systematic review. BMC Pregnancy Childbirth 11: 84. bmcpregnancychildbirth.biomedcentral.com [Accessed January 2020]

NCT. 2018. Overdue baby - what happens if my baby is late? National Childbirth Trust. www.nct.org.uk [Accessed January 2020]

NICE. 2008a. Inducing labour. CG70. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2008b. Induction of labour. Information for the public. National Institute for Health and Clinical Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2014. Intrapartum care of healthy women and their babies. CG190. Updated February 2017. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2015a. Diabetes in pregnancy: management from preconception to the postnatal period. NG3. Updated August 2015. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2015b. Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section. IPG528. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2015c. Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section. Information for the public. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

NICE. 2019. Hypertension in pregnancy: diagnosis and management. NG133. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed January 2020]

RCOG. 2013. Induction of labour at term in older mothers. Scientific impact paper no. 34. Royal College of Obstetricians and Gynaecologists. www.rcog.org.uk [Accessed January 2020]

Thomas J, Fairclough A, Kavanagh J, Kelly AJ. 2014. Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term. Cochrane Database Syst Rev 6: CD003101.

de Vaan MD, Ten Eikelder ML, Jozwiak M et al. 2019. Mechanical methods for induction of labour. Cochrane Database Syst Rev (10): CD001233. www.ncbi.nlm.nih.gov [Accessed January 2020]

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Studio Memoir for BabyCenter Your labour is described as "induced" when it's started artificially. You'll be offered an induction of labour if your doctor thinks that it is safer for your baby to be born sooner rather than continuing with your pregnancy (NICE 2008a).

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41 weeks? 42 weeks? The research.

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Updated: August 2019
In Australia 33% of labours are induced ( 40.5% of first time mothers). The most common reason for induction is to prevent a 'prolonged pregnancy'. That's an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of 'due dates' or rather 'guess dates' here - I discuss estimating birth dates in my book. This post will focus on induction of labour to prevent a 'prolonged' pregnancy and the complexities of risk in this situation.

A quick word about risk

I don't particularly like the concept of 'risk' in birth. There are all kinds of problems associated with providing care based on risk rather than on individual women. However, risk along with 'due dates' is here to stay, and women usually want to know about risks. Risk is a very personal concept and different women will consider different risks to be significant to them. Everything we do in life involves risk. So when considering whether to do X or Y there is no 'risk free' option. All women can do is choose the option with the risks they are most willing to take. However, in order to make a decision women need adequate information about the risks involved in each option. If a health care provider fails to provide adequate information they could be faced with legal action. Induction for prolonged pregnancy is not right or wrong if the choice is made by a woman who has an understanding of all the options and associated risks. As a midwife I am 'with woman' regardless of her choices. It is my job to share information and support decisions - not to judge.

What is a prolonged pregnancy?

Before we go any further lets get some definitions clear:

Term (as in a 'normal' and healthy gestation period): is from 37 weeks to 42 weeks.

Post-dates: the pregnancy has continued beyond the decided due (guess) date ie. is over 40 weeks.

Post-term: the pregnancy has continued beyond term ie. 42+ weeks.

The World Health Organization's definition of a 'prolonged pregnancy' is one that has continued beyond 42 weeks ie. is post-term. However, induction is usually offered when a pregnancy becomes post-dates with the aim of preventing it becoming 'prolonged'. Therefore, very few women experience a prolonged pregnancy - in Australia only 0.6% of pregnancies continue beyond 42 weeks.

The idea of a prolonged pregnancy assumes that all women naturally gestate their babies for the same length of time. However, it seems that genetic differences may influence what is a 'normal' gestation time for a particular woman. For example, Morken, Melve and Skjaerven (2011) found "a familial factor related to recurrence of prolonged pregnancy across generations and both mother and father seem to contribute." Therefore, if the women in your family gestate for 42 weeks so might you. The length of gestation may also be influenced by factors such as diet ( McAlpine et al. 2016).

The initiation of labour is likely caused by the baby who secretes surfactant protein and platelet-activating factor into the amniotic fluid as their lungs mature ( Mendelson 2009; Science Daily). This results in an inflammatory response in the mother's uterus that initiates labour.

The risks associated with waiting for spontaneous labour

Ageing placenta?

Some people believe that the placenta has a best before date and starts to deteriorate after 40 weeks resulting in reduced nutrition and oxygen for the baby. There is evidence that the structure and biochemistry of the placenta changes as pregnancy develops. Some scientists interpret these changes as the placenta growing and adapting to meet the changing needs of the baby: "There is, in fact, no logical reason for believing that the placenta, which is a fetal organ, should age while the other fetal organs do not..." Others argue that these changes are due to the ageing and deterioration of the placenta. However, tests of placental function show no changes in post-dates pregnancies ( Madruzzato et al. 2010). In practice, I have seen signs of placental shut down (ie. calcification) in placentas at 37 weeks and I have seen big juicy healthy placentas at 43 weeks. Sophie Messenger write more about 'the myth of the ageing placenta' here.

Big baby

People also have concerns that the baby will grow huge and therefore be difficult to birth. There is evidence that babies continue to grow bigger the longer they gestate, and this contradicts the above theory about the ageing placenta. If the placenta stops functioning, how does the baby continue to grow so well? Big babies are pretty good at finding their way out of their mothers expandable pelvis. The research about complications relating to big babies suggests that it is the interventions carried out when a baby is assumed to be big - rather than the actual size of the baby - that mostly contributes to complications ( Sadeh-Mestechkin et al. 2008; Blackwell et al. 2009; Peleg et al. 2015).

Meconium liquor

There is an increased chance that the baby will pass meconium as his/her bowels mature. I have written about this scenario in another post.

Perinatal death

The general rate of perinatal death (stillbirth + newborn death) increases as pregnancies advance beyond term. The rate remains small but is statistically significant. For example a systematic review and meta-analysis ( Muglu et al. 2019) reported that: "The overall gestation-week-specific prospective risk of stillbirth steadily increased with gestational age, from 0.11 per 1,000 pregnancies at 37 weeks to 3.18 per 1,000 at 42 weeks gestation... The risks of newborn death remained constant between 38 and 41 weeks, and only increased beyond 41 weeks" .

Post-dates induction of labour reduces the general rate of perinatal death. A Cochrane Review summarises the research examining induction vs waiting: "There were fewer baby deaths when a labour induction policy was implemented after 41 completed weeks or later." However, it goes on to say: "...such deaths were rare with either policy...the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks." Hands up all the women who had a discussion with their care provider about the relative and absolute risks of waiting vs induction...

Essentially, according to the available research, if you are induced at 41 weeks your baby is less likely to die during, or soon after birth. However, the chance of your baby dying is small either way - less than 1%... or 30 out of every 10,000 for those waiting vs 3:10,000 for those induced. This research article reports the relative and absolute risk of stillbirth at various gestations with waiting vs induction. The authors state that 1476 women would need to have an induction to prevent 1 stillbirth at 41 weeks gestation.

Reviews are only as good as the research they review and there are some concerns about the quality of the available research. The World Health Organization recommends induction after 41 weeks based on the Cochrane Review above but acknowledges the evidence is "low-quality evidence. Weak recommendation". Another review of the literature in the Journal of Perinatal Medicine ( Mandruzzato et al. 2010) concluded: "It is not possible to give a specific gestational age at which an otherwise uncomplicated pregnancy should be induced."

One of the main problems with quantitative research is that it rarely answers the question 'why', and rather focuses on 'what' (happens). For example, congenital abnormalities of the baby and placenta are associated with post-term pregnancy and this may account for the increased risk in some cases, rather than the length of gestation ( Mandruzzato et al. 2010). Quantitative research also takes a general perspective rather than addressing the risk for an individual woman in a particular situation. For example, is the prolonged pregnancy as sign of pathology, or does this woman come from a family of women who have a longer gestational timeframe? For a woman who has previously gestated to post-term without complications, there is no increased chance of an adverse outcome ( Kortekaas et al. 2015).

The risks associated with induction

It can be difficult to untangle and isolate the risks involved with induction because usually more than one risk factor is occurring at once (eg. syntocinon, CTG, epidural). In addition, there are differences in outcomes and risks between women who have previously laboured, and women having their first baby. It is important for women to consider their own individual factors and how they alter their individual risk profile. Care providers should also share individualised information when discussing induction options.

General risks associated with the induction procedure and medications

The induction process is a fairly invasive procedure which usually involves some or all of the following (you can read more about the process of induction here). There are a number of minor side effects associated with these medications/procedures (eg. nausea, discomfort etc.) There are also more significant risks:

The most extreme of these risks are rare, but fetal distress and c-section are fairly common. The potential effects of uterine hyperstimulation on the baby are well known ( Simpson & James 2008)- which is why continuous fetal monitoring is recommended during induction. This may also explain the association between induction and cerebral palsy ( Elkamil et al. 2010)

Induced contractions are usually more painful than a physiological contractions. Syntocinon (pitocin) produces strong contractions without the gentle build up and endorphin release of natural contractions. The National Institute of Clinical Excellence (UK) state that health care professionals should discuss this with women when offering induction "recognising that women are likely to find induced labour more painful than spontaneous labour".

Most research comparing induction with spontaneous labour combines populations of 'experienced' labourers with first timers. These studies report conflicting findings. For example, some studies report a lower chance of c-section with induction for this mixed group ( Gülmezoglu et al. 2012; Mishanina et al. 2014; Wood et al. 2014). In contrast, more recent studies have found increased rates of c-section with induction ( Zhao, Flatley, Kumar 2017; Ekéus & Lindgren 2016). A 2019 review compared the timing of induction for low risk pregnancies - 41 weeks vs 42 weeks ( Rydahl, Eriksen & Juhl 2019). The review used stricter inclusion criteria than previous reviews to "enhance the methodological quality and increase the relevance for contemporary maternity care"; and reported that: "Induction at 41+0-6 gestational weeks compared to 42+0-6 gestational weeks was found to be associated with an increased risk of overall cesarean section."

Risks for women who have had a previous labour

Women who have laboured before respond more effectively to syntocinon (pitocin) because they have more oxytocin receptors in their uterine muscle. Therefore, this group of women are more likely to experience a successful induction and avoid c-section. They are likely the reason for lower or similar rates of c-section the mixed group research discussed above. However, they are at increased risk of hyperstimulation with prostaglandin medication and/or syntocinon. So doses are usually smaller and very carefully monitored to avoid fetal distress. Women who have given birth vaginally before, are also at increased risk of perineal tearing if they have syntocinon induced contractions.

Risks for women having their first labour induced

Inducing a first labour requires higher rates of syntocinon, and the length of labour is usually longer. It is not surprising that first time mothers are more than 3 x more likely to opt for an epidural during an induction ( Selo-Ojeme et al. 2011); and epidural analgesia increases the chance of ending up with an instrumental birth - ventouse or forceps ( Anim-Somuah et al. 2018)

The majority of research comparing induction (IOL) with spontaneous (SP) labour in populations of first time labourers report increased c-section rates:

Another US study ( Ehrenthal et al. 2010) reported that after "adjusting for maternal demographic characteristics, medical risk, and pregnancy complications. The contribution of labor induction to cesarean delivery in this cohort was estimated to be approximately 20%." This brings up interesting risk comparisons relating to c-section vs the risk of post-dates perinatal death (see above). For example, induction is recommended because there is a less than 0.3% chance of perinatal death in post-dates pregnancies (see above). However, the chance of a significant complication during c-section (eg. hysterectomy) is higher than the chance of perinatal death in a post-dates pregnancy; and after a c-section the chance of stillbirth during a subsequent pregnancy increases to 0.4% - again, a higher rate than a postdates pregnancy.

A recent study causing a stir is the ARRIVE RCT trial (US) which reported lower c-section rates in the induction group (18.6% vs 22.2%). This one study is now being used to justify recommending early induction at 39 weeks - primarily because the findings align with cultural norms and preferences (see this post re. implementation of research findings into practice). Whilst I don't want to give this study unwarranted attention... it keeps popping up in conversations, workshops, and presentations. Like the perineal bundle - it is an unavoidable topic in the birth world. So here goes (briefly)... recommendations based on the trial are problematic in a number of ways. The findings and recommendations have been constructively critiqued by academics, midwives and obstetricians ( Dekker 2018; Carmichael & Snowdon 2019; Davis-Tuck et al. 2018; Scialli 2019). In summary, the main points are:

Only 27% of eligible women agreed to participate - Findings can only be applied to women who are willing to have a medically managed birth.

94% of the woman were cared for by private obstetricians in US medical settings - Findings cannot be applied to other types of care providers and settings which have much lower rates of c-section and higher rates of spontaneous vaginal birth.

Care providers were not blinded - Knowing about the trial my have altered their practice.

IOL reduced c-section rates by 4% - This cannot be used to recommend IOL to prevent c-section. Other factors have a much more significant effect on c-section rates eg. continuity of midwifery care; place of birth; intermittent auscultation in labour; etc.

The primary outcome measure for this study was perinatal outcome (ie. the baby) - IOL made no difference to the immediate outcomes for the baby, and the study did not address the long-term harm of early birth for the baby (eg. brain development).

In relation to the primary outcome measure - perinatal outcomes. Another study ( Selo-Ojeme et al 2011) found that outcomes for the baby were worse when a first labour was induced: "babies born to mothers who had an induction were significantly more likely to have an Apgar score of <5 at 5mins and an arterial cord pH of <7.0 ".

The experience of induction

Research into induction tends to focus on physical outcomes rather than women's emotional/psychological experiences of the process.

Choosing induction will totally alter the birth experience and the options open to you. Women need to know that agreeing to induction means agreeing to continuous monitoring and an IV drip, which will limit movement. Induced contractions are usually more painful than natural contractions and the inability to move and/or use warm water (shower or bath) reduces the ability to cope. The result is that an epidural may be needed. An induced birth is not a physiological birth and requires monitoring (vaginal exams) and time frames. Basically you have bought a ticket on the intervention rollercoaster. For many women this is fine and worth the risk, but I encounter too many women who are unprepared for the level of intervention required during an induction. This does not mean you have to hand over control of your decisions or your body; and in my book I include a chapter on creating a birth plan for induction of labour.

There have been some studies examining women's experience of induction. A UK study by Henderson and Redshaw (2013) found that "women who were induced were generally less satisfied with aspects of their care and significantly less likely to have a normal delivery. In the qualitative analysis the main themes that emerged concerned delay, staff short- ages, neglect, pain and anxiety in relation to getting the induction started and once it was underway; and in relation to failed induction, the main themes were plans not being followed, wasted effort and pain, and feeling let down and disappointed.". A German study ( Schwarz et al. 2016) concluded that: "women's expectations and needs regarding IOL are widely unmet in current clinical practice... and that "there is a need for evidence-based information and decisional support for pregnant women who need to decide how to proceed once term is reached."

A recent systematic review ( Coates et al. 2019) of qualitative research into women's experiences of induction of labour concluded that induction "is a challenging experience for women, which can be understood in terms of the gap between women's needs and the reality of their experience concerning information and decision-making, support, and environment. "

Alternatives to medical induction

Waiting for spontaneous labour

Around 90% of women who wait for spontaneous labour will give birth before 42 week, and only 1% will go beyond 43 weeks ( Gülmezoglu et al. 2012). Most guidelines recommend additional monitoring of the baby - however no form of monitoring reduces the chance of complications ( Gülmezoglu et al. 2012).

'Natural' induction?

There are a number of 'alternative' or 'natural' induction methods available (I have a chapter discussing the evidence for various methods in my book). However, trying to get the body/baby to do something it is not ready to do is still an intervention whether it is with medicine, herbs, therapies, techniques... or anything else. Interventions of any kind can have unwanted effects and consequences. Medical inductions take place with close monitoring of mother and baby and access to medical support if a complication arises. Alternative inductions do not have this level of monitoring or back up.

However, 'interventions' (massage, acupuncture, etc.) that are aimed at relaxing the mother and fostering trust, patience and acceptance may assist the body/baby to initiate labour if the physiological changes have already taken place.

Summary

A significant minority of babies will not be born by 41 weeks gestation. Whilst the definition of a prolonged pregnancy is 42 weeks+, induction is usually suggested during the 41st week. Women need to be given adequate information about the risks and benefits involved with either waiting or inducing in order to make the choice that is right for them. There is no risk free option. The risk of perinatal death is extremely small for both options. I know women who have lost a baby in the 41st week of pregnancy, and women who have lost a baby as a result of the induction process. For first time mothers the induction process poses particular risks for themselves and their babies. Each individual woman must decide which set of risks she is most willing to take - and be supported in her choice.
You can read more about induction in my book Why Induction Matters

Further resources

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Post-Dates Induction of Labour: balancing risks

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Updated: August 2019 In Australia 33% of labours are induced (40.5% of first time mothers). The most common reason for induction is to prevent a 'prolonged pregnancy'. That's an awful lot of babies outstaying their welcome and requiring eviction. I am not going to get stuck into the concept of 'due dates' or rather 'guess dates'...

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Isla Miller (and cheeks)

Big babies are normal in well resourced countries. Over 10% of babies born in the UK and Australia weigh 4kg (8lb 13oz) or more. Healthy well nourished women grow healthy well nourished babies. Genetic factors also influence the size of babies (big babies run in families); and each baby a woman has usually weighs more than the last. Babies also continue to grow at the end of pregnancy (because placentas continue to nourish them rather than switch off) - so a baby will be bigger at 42 weeks than they were at 40 weeks.

However, abnormal blood glucose levels (BGLs) - with uncontrolled gestational diabetes (GD) - can also cause a baby to grow big. Babies who are big because of high BGLs are a different shape to 'normally' large babies. In particular, their shoulders and chest are larger and fatter, and they are more likely to encounter complications at birth. Unfortunately, research into big babies usually combines the outcomes for GD babies with non-GD babies.

Estimating size

The only way to accurately assess the weight of a baby is to weigh them after birth. Clinical assessment ie. palpating and measuring pregnant bumps is incorrect more than 50% of the time ( Chauhan et al. 2005). Even the best available method - measuring the baby's abdomen with an ultrasound - only predicts the weight of the baby within 15% of their actual weight ( Rossi et al. 2013). Therefore, lots of women are being incorrectly told that their baby is 'big'. A US study found that one out of three women were told their baby was 'too big' based on ultrasound ( Cheng et al. 2015). In this study the average birth weight of the group of babies suspected of being big was 7lb 13oz - ie. not big at all.

Birth complications?

Giving birth to a big baby is associated with an increased chance of particular outcomes - notice I am using the term 'associated' not 'caused'. The main complication associated with big babies is shoulder dystocia. The incidence of shoulder dystocia increases with the size of the baby. For example, it occurs with around 1% of babies weighing less than 3.9kg (8lbs 8oz), compared to 5-9% of babies weighing between 3.9kg and 4.5kg (9lb 9oz) ( Politi et al. 2010). Other less likely complications associated with big babies are severe perineal tearing (0.6%) and postpartum haemorrhage (1.7%) ( Weismann-Brenner et al. 2012). I have previously written about how to reduce the chance of these complications:

Care provider fear

However, research suggests that the complications associated with big babies may be due to interventions carried out when a baby is suspected to be big. Care providers are more likely to diagnose slow progress during labour and recommend a caesarean if they suspect the baby is big ( Blackwell et al. 2009). Women who are told that they have a 'big baby', and are counselled about potential complications, are significantly more likely to choose a planned caesarean ( Peleg et al. 2015). One study compared the outcomes of a group of women with suspected big babies with a group of women who unexpectedly gave birth to a big baby ( Sedah-Mestechkin et al. 2008). Women who were suspected of having a big baby were three times more likely to have an induction or caesarean, and were four times more likely to have complications such as severe perineal tearing and postpartum haemorrhage. In this study there were no differences in the incidence of shoulder dystocia between the two groups.

Therefore, when a baby is suspected of being big, a woman has an increased chance of interventions during birth, and of experiencing complications caused by those interventions, even if the baby is not actually big.

The perception of a baby's size influences outcomes more than the actual size of the baby

Induction?

A Cochrane Review comparing induction of labour before 40 weeks for a suspected big baby with waiting for spontaneous labour, found that induction decreased the incidence of shoulder dystocia from 6.8% to 4.1%. However, the review also found an increased rate of perineal tearing in the induction group of 2.6% compared to 0.7% in the spontaneous labour group; and an increase in the treatment of jaundice for the baby (11% compared to 7%). The review also notes that "antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed." There are a number of risks associated with inducing labour (see this post and this post) that need to be considered against the potential risks of of birthing a big baby.

NICE guidelines and World Health Organisation guidelines both state that induction of labour should not be carried out simply because a baby is suspected of being big. Interestingly, Queensland Health induction guidelines do recommend induction if a baby is estimated to be big via ultrasound. Yet the Queensland Health gestational diabetes guidelines state that "estimation of fetal weight by clinical assessment or USS can have significant margins of error".

Summary

The estimation of a baby's size via ultrasound is inaccurate. The complications associated with big babies may reflect care provider fear and practice. International guidelines do not recommend induction for a suspected big baby. Women need to be given this information before agreeing to an ultrasound scan aimed at estimating the size of their baby. Once the 'big baby' label is applied it cannot be removed and may alter the birth experience and outcome.

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Big Babies: the risk of care provider fear

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Isla Miller (and cheeks) Big babies are normal in well resourced countries. Over 10% of babies born in the UK and Australia weigh 4kg (8lb 13oz) or more. Healthy well nourished women grow healthy well nourished babies. Genetic factors also influence the size of babies (big babies run in families); and each baby a woman...

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Is Induction more likely to lead to caesarean?

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Is Induction more likely to lead to caesarean?

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new research

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Imagine how much easier this would be if she wasn't lying on her back!

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Stages Of Labor: Early Labor, Active Labor and Transition Stage

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in case you were wondering how baby gets through...

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North Surrey Midwife - The wonderful pelvis.wmv

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note how the coccyx moves

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Olha a perfeição de um parto na vertical. Parir de cócoras, em 4 apoios é naturalmente normal.

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Post by equipefloreser.

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how babies are born

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Nathan Haniger for BabyCenter

In this article

What is childbirth like?

Every woman's experience of labour and birth is different. Nobody can predict what your labour will be like, or how long it will last.

But there are plenty of things you can do to prepare yourself and, understanding what happens to your body and your baby during labour is an important first step.

What are the stages of labour?

Labour moves forward in three clear stages:

First stage: when contractions gradually open up the cervix, which is the neck of your womb (uterus). The first stage consists of early labour, active labour, and the transitional phase.

Second stage: when you push your baby out into the world.

Third stage: when you deliver the placenta.

There is also a phase called prelabour, or the latent phase, which is when your body gears up for the first stage of labour.
What happens in prelabour?

During pregnancy, your cervix is closed and plugged with mucus, to keep out infection. Your cervix is long and firm, giving a strong base to your womb. It's also in a position that points slightly towards your back (posterior position).

Before labour can start properly, your cervix has to go through some changes. It has to move forward (anterior position), soften and shorten (Simkin and Ancheta 2011). The softening of your cervix is often called ripening.

Prelabour changes may take hours, days or even weeks (APA 2018, Simkin and Ancheta 2011). You may not notice anything happening. Or you may be aware of contractions that may range in intensity and disturb your sleep, even though labour has yet to get going properly (Simkin and Ancheta 2011).

What happens in the first stage of labour?

In the first stage of labour, your cervix has to open (dilate), so your baby can be born. The muscles of your womb tighten with each contraction and then release, gradually drawing your cervix up into the lower section of your womb.

In the early phase of first stage labour, your cervix may open gradually. It may seem as if no changes are happening at all. Early labour can be slow and your contractions may not last for long and have lengthy gaps between them. They may even stop for a while before starting again.

As you enter the active phase of first stage labour, when your cervix has dilated to about 4cm (NICE 2014), the contractions usually last longer, and become more frequent and powerful.

Towards the end of the first stage, your labour may become much more intense. This phase of labour is called transition (Downe and Marshall 2014). By the end of the first stage your cervix will be fully dilated or you may get the urge to push (Downe and Marshall 2014).

Read more about the first stage of labour.

What happens in the second stage of labour?

This is the stage when your baby is born. During the second stage of labour, your baby will start to move down your vagina (the birth canal).

You may not feel the urge to push with your contractions straight away. Midwives call this the passive second stage. When your baby has descended enough that your midwife or birth partner can see him, and you have the urge to push your baby out, you're in active second stage (NCCWCH 2014, RCM 2012a)

During the active second stage, you'll feel the pressure of your baby's head low down in your pelvis, and with each contraction, you may feel strong urges to bear down. Listen to your body, and push in response to the urges (Lemos et al 2017, NCCWCH 2014). Take a few breaths between pushes if that's what feels right (RCM 2012a).

With every push, your baby will move further through your pelvis, but at the end of the contraction, he'll probably slip back a little again. This is normal and gives the muscles of your pelvic floor time to stretch gradually (Downe and Marshall 2014). As long as your baby keeps gradually moving down, you're doing fine (RCM 2012a).

Keeping upright can help you and your baby to progress through the active second stage (Gupta et al 2017, NCCWCH 2014).

When your baby's head is visible at the entrance to your vagina and stays there when the contraction has ended, it's called crowning.

Your midwife will tell you when she can see your baby's head, and may ask you to stop pushing and blow or sigh out your breaths (Downe and Marshall 2014). This helps you to resist the urge to bear down for two contractions or three contractions, so that your baby is born gently and slowly.

Taking this approach may help to protect your perineum (the area between your vulva and your anus)(Downe and Marshall 2014). You'll probably feel a hot, stinging sensation, as the opening of your vagina starts to stretch around your baby's head (Capogna et al 2010). Your midwife may use warm compresses to support your perineum as it stretches to help prevent a tear (Aasheim et al 2017).

Once you've birthed your baby, the second stage is over (NICE 2014, RCM 2012a). Your midwife may wipe your baby with a clean towel and then place him on your tummy or chest for a skin-to-skin (Downe and Marshall 2014, NICE 2014) cuddle.

Read more about the second stage of labour.

What happens in the third stage of labour?

The third stage of labour begins once your baby is born and ends when you deliver the placenta and the empty bag of waters that are attached to the placenta (membranes). These come away as your womb contracts down after the birth.

Your midwife will offer you an injection for the third stage that helps your womb to contract down and the placenta to come away ( managed third stage) (NCCWCH 2014).

The injection may cause side-effects such as nausea and vomiting, because of the drugs used (NCCWCH 2014). You won't have to do any pushing, as once the placenta is detached, your midwife will gently pull it out, along with the membranes from the amniotic sac (NICE 2014).

If all went well in your pregnancy and labour, you can choose instead to have a natural (physiological) third stage (NICE 2014, RCM 2012c). This is when you deliver the placenta without an injection.

With a natural third stage your contractions will be noticeable, but weaker, when they begin again. The placenta will peel away from the wall of your womb and move down into your vagina. You may get the urge to push as this happens (Begley 2014, RCM 2012c).

Easing yourself into an upright position, cuddling your baby skin-to-skin, and starting to breastfeed him, may all help to stimulate your body to expel the placenta (RCM 2012c).

Whether you have a natural or a managed third stage, it's recommended that your midwife waits at least a few minutes before clamping the cord. While you're waiting to expel the placenta, the cord will continue to pulse with nutrient-rich blood. Waiting gives your baby a helpful boost of this blood (NCCWCH 2014). While all this is going on, you're likely to be cuddling and getting to know your newborn better.

As long as you and your baby are well, you should be left in peace to have special time together. Your midwife should let you have at least an hour of gazing at, and possibly feeding, your new baby. After that, your midwife will ask to carry out the standard newborn checks. These include weighing your baby, measuring his head size, and taking his temperature (NICE 2014).

Read more about the third stage of labour.

Last reviewed: September 2019

References

APA. 2018. Prodromal labour? American Pregnancy Association. americanpregnancy.org [Accessed September 2019]

Begley C. 2014. Physiology and care during the third stage of labour. In: Marshall JE, Raynor MD. eds. Myles Textbook for Midwives. 16th ed. Edinburgh: Churchill Livingstone, 395-416

Capogna G, Camorcia M, Stirparo S, et al. 2010. Multidimensional evaluation of pain during early and late labor: a comparison of nulliparous and multiparous women. Int J Obstet Anesthesia 19(2):167-70

Downe S. Marshall JE. 2014. Physiology and care during the transition and the second stage phases of labour. In: Marshall JE, Raynor MD. eds. Myles Textbook for Midwives. 16th ed. Edinburgh: Churchill Livingstone, 367-93

Gupta JK, Sood A, Hofmeyr GJ, et al. 2017. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews (5): CD002006. www.cochranelibrary.com [Accessed September 2019]

Lemos A, Amorim MMR, Dornelas de Andrade A, et al. 2017. Pushing/bearing down methods for the second stage of labour. Cochrane Database of Systematic Reviews (3): CD009124. www.cochranelibrary.com [Accessed September 2019]

NCCWCH. 2014. Intrapartum care: care of healthy women and their babies during childbirth. Updated Feb 2017. National Collaborating Centre for Women's and Children's Health, Clinical guideline, 190. www.nice.org.uk [Accessed September 2019]

NICE. 2014. Care of women and their babies during labour and birth: information for the public. Updated Feb 2017. National Institute for Health and Care Excellence. www.nice.org.uk [Accessed September 2019]

RCM. 2012a. Second stage of labour. Royal College of Midwives Trust, Evidence based guidelines for midwifery-led care in labour

RCM. 2012b. Care of the perineum. Royal College of Midwives Trust, Evidence based guidelines for midwifery-led care in labour

RCM. 2012c. Third stage of labour. Royal College of Midwives Trust, Evidence based guidelines for midwifery-led care in labour

Simkin P, Ancheta R. 2011. The labor progress handbook: early interventions to prevent and treat dystocia. 3rd ed. Chichester: Wiley Blackwell

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Nathan Haniger for BabyCenter In this article Every woman's experience of labour and birth is different. Nobody can predict what your labour will be like, or how long it will last. But there are plenty of things you can do to prepare yourself and, understanding what happens to your body and your baby during labour is an important first step.

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Royal College of Obstetricians & Gynaecologists

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The Government has today accepted the recommendation from the Medicines and Healthcare products Regulatory Agency (MHRA) to authorise Oxford University/AstraZeneca's COVID-19 vaccine for use. The Joint Committee on Vaccination and Immunisation (JCVI) has also published its latest advice for the priority groups to receive the Oxford University/AstraZeneca and the Pfizer/BioNTech vaccines. This includes updated advice for pregnant and breastfeeding women who meet other criteria for priority vaccination.

The JCVI confirms that although the available data do not indicate any safety concern or harm to pregnancy, there is insufficient evidence to recommend routine use of COVID-19 vaccines during pregnancy.

However, the JCVI now advises that if a pregnant woman meets the definition of being clinically extremely vulnerable, then she should discuss the options of COVID-19 vaccination with her obstetrician and/or doctor. This is because their underlying condition may put them at very high risk of experiencing serious complications of COVID-19. The most likely relevant groups of pregnant women are:

Solid organ transplant recipients

Those with severe respiratory conditions including cystic fibrosis and severe asthma

Those who have homozygous sickle cell disease

Those receiving immunosuppression therapies sufficient to significantly increase risk of infection

Those receiving dialysis or with chronic kidney disease (stage 5)

Those with significant congenital or acquired heart disease

Additionally, pregnant women who are frontline health or social care workers, including carers in a residential home, can also discuss the option of vaccination. This is because the risk of exposure to COVID-19 may be higher, even if they have a lower risk of experiencing complications if they are otherwise well.

The benefits and risks of COVID-19 vaccination in pregnancy should be discussed on an individualised basis. This should include a discussion around the lack of safety data for these specific vaccinations for pregnant or breastfeeding women, and an acknowledgement that there is no known risk associated with giving other non-live vaccines to pregnant women.

The JCVI also now advises that there is no known risk in giving these vaccines to breastfeeding women. Breastfeeding women should therefore be offered vaccination if they are otherwise eligible, for example if they are a frontline health or social care worker, including a carer in a residential home. Women should be advised that there is lack of safety data for these specific vaccinations in breastfeeding.

We welcome the recognition of pregnant and breastfeeding women as a group where clinical guidance and further research is needed. We are urgently working with the Department of Health and Social Care to set up a COVID-19 vaccine registry through the UK Obstetric Surveillance System (UKOSS) and the UK Teratology Information Service (UKTIS) for pregnancy (separate to the planned clinical trials) to ensure that adequate safety data are collected for all women in these groups who are given one of the approved COVID-19 vaccines.

We are recommending that pregnant women who might be eligible for vaccination should receive it through their maternity unit, or notify their local maternity unit when it is received. This is so that maternity staff can report it to the UKOSS/UKTIS vaccine registry, including reporting of follow-up post-vaccination of the women and their babies. The RCOG and RCM will publish further details and advice on prescribing the COVID-19 vaccination for maternity units in the coming weeks.
Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said:
"This updated advice from the JCVI means that vaccination in pregnancy should be considered in women who are frontline health or social care workers or have underlying conditions that put them at very high risk of being infected with, transmitting or experiencing serious complications of COVID-19.

"We support this risk based approach until data exist to support routine vaccination in pregnant women. We also welcome the advice that breastfeeding women may be offered vaccination and that those who are trying to become pregnant do not need to avoid pregnancy after vaccination.

"For frontline health and social care workers, and other priority groups, informed decision-making should be facilitated. It is important that women continue to be offered occupational protection during pregnancy, regardless of their vaccination choice.

"Along with the Royal College of Midwives and other professional bodies, we're calling on the UK government to fund research studies to establish the suitability of any approved COVID-19 vaccines in pregnant and breastfeeding women.

"The UK has a world leading research and development sector to support a national effort to research the vaccine's suitability for use in pregnancy and we are calling for research trials, supported by the Vaccine Taskforce, to begin urgently to get evidence on safety. The outcomes of this research will be vital for the over 800,000 women each year who conceive, as well as the many women planning a pregnancy."
Gill Walton, Chief Executive of the Royal College of Midwives (RCM) said:
"Today's updated guidance from the JCVI means that clinically vulnerable pregnant women will now have access to the COVID-19 vaccination which is good news. That said the vast majority of pregnant women will not be eligible for the vaccine and this is because although the current available data does not indicate any safety concern or harm to pregnant women, there is insufficient evidence to recommend routine use of COVID-19 vaccines during pregnancy.

"Together with the Royal College of Obstetricians and Gynaecologists the RCM is calling on the Government to speed up research to assess the safety of the vaccine in pregnancy. In the meantime, all pregnant women should take up the offer of the free flu vaccination, so they are protected against flu viruses circulating this winter and if you have any concerns please talk to your midwife or GP."
ENDS Notes to editors
This statement is supported by the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, British Maternal and Fetal Medicine Society, Macdonald Obstetric Medicine Society, UK Teratology Information Service and the National Perinatal Epidemiology Unit.

The advice from the Joint Committee on Vaccination and Immunisation (JCVI) on COVID-19 vaccination for women who are pregnant or who are breastfeeding (30 December 2020):
Women who are pregnant
There is no known risk associated with giving non-live vaccines during pregnancy. These vaccines cannot replicate, so they cannot cause infection in either the woman or the unborn child.

Although the available data do not indicate any safety concern or harm to pregnancy, there is insufficient evidence to recommend routine use of COVID-19 vaccines during pregnancy.

JCVI advises that, for women who are offered vaccination with the Pfizer-BioNTech or AstraZeneca COVID-19 vaccines, vaccination in pregnancy should be considered where the risk of exposure to Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV2) infection is high and cannot be avoided, or where the woman has underlying conditions that put them at very high risk of serious complications of COVID-19. In these circumstances, clinicians should discuss the risks and benefits of vaccination with the woman, who should be told about the absence of safety data for the vaccine in pregnant women.

JCVI does not advise routine pregnancy testing before receipt of a COVID-19 vaccine. Those who are trying to become pregnant do not need to avoid pregnancy after vaccination.
Women who are breastfeeding
There is no known risk associated with giving non-live vaccines whilst breastfeeding. JCVI advises that breastfeeding women may be offered vaccination with the Pfizer-BioNTech or AstraZeneca COVID-19 vaccines.

The developmental and health benefits of breastfeeding should be considered along with the woman's clinical need for immunisation against COVID-19, and the woman should be informed about the absence of safety data for the vaccine in breastfeeding women.

The MHRA has also published additional updates relating to use of the Pfizer/BioNTech vaccine in pregnancy and women who are breastfeeding.

The CHM (Commission on Human Medicines) has also reviewed further data for the Pfizer/BioNTech vaccine as it has become available and has recommended the following changes:

Pregnancy and women who are breastfeeding - the vaccine should only be considered for use in pregnancy when the potential benefits outweigh any potential risks for the mother and baby. Women should discuss the benefits and risks of having the vaccine with their healthcare professional and reach a joint decision based on individual circumstances. Women who are breastfeeding can also be given the vaccine. This advice is in line with pregnancy and breastfeeding advice for the Oxford University/AstraZeneca vaccine

Read the RCOG/RCM Q&As for pregnant women on COVID-19 vaccines, pregnancy and breastfeeding.

For media enquiries please contact the RCOG press office on +44 (0)7757 237917 or email pressoffice@rcog.org.uk

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Updated advice on COVID-19 vaccination in pregnancy and women who are breastfeeding

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The Government has today accepted the recommendation from the Medicines and Healthcare products Regulatory Agency (MHRA) to authorise Oxford University/AstraZeneca's COVID-19 vaccine for use. The Joint Committee on Vaccination and Immunisation (JCVI) has also published its latest advice for the priority groups to receive the Oxford University/AstraZeneca and the Pfizer/BioNTech vaccines.

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making the room gentler for labour

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ACTIVE BIRTH - Get off the bed

I was teaching my midwifery student today about looking at the delivery room and how as midwives we can utilise the space... | By Gas and Air | Facebook

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ACTIVE BIRTH - Get off the bed

I was teaching my midwifery student today about looking at the delivery room and how as midwives we can utilise the space...

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getting babies into good positions for birth

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Parenthood Starts with Pregnancy

You and your baby are working together! Your job is to dilate, baby's job is to rotate. Empower yourselves with our daily activities, body balancing techniques, and smart birth positions for a more comfortable, confident birth.

Proactive Preparation for Easier Birth

Join others who are enthusiastic for your life-giving year! Find a Spinning Babies ® Certified Parent Educator to start using techniques for comfort in pregnancy and smoother progress in labor through our unique approach to physiological birth.

Help Change Birth on Earth

Find Spinning Babies ® Workshops and events near you to start helping parents experience a more confident and comfortable birthing process for both themselves and their baby.

For additional education to even further enhance your pregnancy and labor preparation, shop our extensive collection of digital downloads, videos, DVDs, workbooks, and more.

Daily Essentials can be practiced daily throughout pregnancy to help bring balance and comfort - and an easier, shorter birth.

Spinning Babies® Parent Class

Spinning Babies® Parent Class provides clear instructions on how to use Spinning Babies® for a more comfortable and confident pregnancy and labor.

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Spinning Babies - Comfort in Pregnancy and Easier Birth

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Parenthood Starts with Pregnancy You and your baby are working together! Your job is to dilate, baby's job is to rotate. Empower yourselves with our daily activities, body balancing techniques, and smart birth positions for a more comfortable, confident birth. Proactive Preparation for Easier Birth Join others who are enthusiastic for your life-giving year!

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manually turning a baby

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NHS External Cephalic Version (for Breech Baby)

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how babies are turned

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External Cephalic Version - The art of gentle rotation, with visualization of baby's rotation.

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Whittington homebirths & standalone birth centres

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Whittington homebirths & standalone birth centres

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Alongside other NHS organisations across North Central London we are implementing some temporary changes to our maternity, childrens inpatient and childrens urgent and emergency services.

We are asking that expectant mothers to enter our hospital via the Labour Ward reception entrance rather than walking through our hospital. Our hospital remains safe for those who do not have COVID-19 who need to attend; this advice is designed to reduce the number of people walking through the hospital and make it easier for people to remain 2m apart.

You can access the Labour Ward entrance by entering our hospital site near the Emergency Department on Highgate Hill (rather than our main entrance on Magdala Avenue). On entering the site, continue outside past our Emergency Department and the Jenner Exit. The Labour Ward reception is the next entrance on the left. If you find it difficult to walk, you can drive onto the site and ask our colleagues in security to open the vehicle barrier, allowing you to be dropped off right by the entrance. You can see this more clearly on this map of our site.

Maternity patients, should attend all appointments alone unless its absolutely necessary to have a visitor with them. This supports government advice to reduce the transmission of the virus and aims to keep you, your family and staff well.

The only exception to this currently is if you are attending your 12 or 20 week scan where we can allow a partner to come with you.

For any Covid-19 related queries please call our Specialist Maternity Helpline on 07831 122271 between 08:30- 18:00 Monday to Friday.

UPDATE DECEMBER 2020: As we continue to deal with an increase in Covid-19, hospitals are having to change the way they deliver services. To ensure that women and their babies have the safest birth possible, hospital trusts across North Central London are putting in new measures.

Due to the current impact of the pandemic the London Ambulance Service is no longer in a position to guarantee an ambulance response to those women choosing to plan their birth at home, or within one of the capitals three stand-alone birth centres. Because of this we regrettably need to temporarily suspend our home birth service.

Coronavirus is having a significant impact on all NHS services across the country and we are doing everything we can to ensure that the safety of women and their babies is not compromised.

We will be contacting women who were planning to have a home birth in the coming weeks to explain the changes and discuss alternative options. We know that these are extremely difficult times and we want to do whatever we can to reassure women due to give birth and support them to have a safe delivery.

This has been an extremely tough decision for us given the importance of respecting and honouring the birth plans that women have chosen. However, we hope you understand that this is the only safe course of action at this unprecedented time.

We will continue to closely monitor the situation and home birth services will be restored as soon as it is safe to do so.

If you have any questions, please do not hesitate to contact Kaye Wilson, Head of Maternity Commissioning for North Central London at kaye.wilson1@nhs.net.

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Alongside other NHS organisations across North Central London we are implementing some temporary changes to our maternity, childrens inpatient and childrens urgent and emergency services. We are asking that expectant mothers to enter our hospital via the Labour Ward reception entrance rather than walking through our hospital.

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Risks with longer (& shorter) pregnancies

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Risks with longer (& shorter) pregnancies

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What is Entonox?

Entonox is a colourless, odourless gas usually made up of half nitrous oxide and half oxygen. Some hospitals add other substances to make it more effective but this might make women more sleepy (OAA, 2019).

Why is Entonox used in labour?

Nearly 80% of women use Entonox in labour because many find it to be the best option from a range of inhaled pain killers (CQC, 2019). Entonox has no negative effect on contractions, and you and your baby quickly get rid of it from your bodies (Jones et al, 2012).

How is Entonox used in labour?

It's self-administered so you breathe in Entonox through a mouthpiece or mask that you grab when you need it. Your caregiver will show you how to breathe in and out properly through the mouthpiece during a contraction. It takes 15 to 20 seconds to work effectively (NHS, 2017).

How effective is Entonox?

Entonox is said to be of 'moderate' help with pain and is, surprisingly, more effective at easing pain than opioids (Jones et al, 2012; OAA, 2016; OAA, 2019).

Can everyone use Entonox?

Some women say Entonox makes them feel sick so they might want to avoid it.

What are women's experiences of Entonox?

Women who use it like being able to control it themselves (NHS, 2017).

Does Entonox have any side effects?

There are no significant side effects for women or babies when used appropriately - in other words, during contractions only (NHS, 2017; Jones et al, 2012). Slight side effects some women experience are feeling dizzy or being sick and they often say they have a dry mouth (Jones et al, 2012; OAA, 2016; Lowth, 2017; NHS, 2017).

Does Entonox affect labour or breastfeeding?

It has no impact on how labour progresses, and there is no suggestion of any impact on breastfeeding (OAA, 2016).

Does Entonox have any long-term effects?

None.

How long do the effects of Entonox last?

You can stop taking it at any point if you choose. The effects of Entonox wear off in minutes (OAA, 2019).

Where and when can I use Entonox during labour?

You can have Entonox wherever you plan to give birth. If you're planning a home birth, the midwife will bring Entonox with them. You can use it at any time in labour (OAA, 2019).

Can my partner help with Entonox?

Your partner can help by holding the mouthpiece between contractions, while you're not using it, and then offering it back to you. This is particularly important if you're in a bath or birth pool as you don't want the mouthpiece to slip into the water.

Can I use Entonox with other types of pain relief?

You can use Entonox at the same time as TENS, water, pethidine/diamorphine or self-help measures (e.g. hypnobirthing).

Will I need any extra procedures with Entonox?

There is no need for extra monitoring or any other additional procedures with Entonox (OAA, 2016).

Are there any other considerations with Entonox?

When discussing options for working with the pain of labour, your midwife might mention the environmental impact of Entonox. This is not to discourage you from using it but because some women might make an informed decision not to. Entonox is a greenhouse gas that accounts for over 2% of the NHS carbon footprint, and about a third of that is used by women in labour (Sulbaek et al, 2012; Sustainable Development Unit, 2013).

Other pain relief options also have environmental impacts but Entonox is the first one that has been highlighted (Sustainable Development Unit, 2013). NHS Trusts will also be working to address the hospital's environmental impact in other ways, such as lower temperatures, improved recycling, and transport (Sustainable Development Unit, 2013).
This page was last reviewed in August 2019.
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 pregnancy and life with a new baby.

Research from the Royal College of Obstetricians and Gynaecologists (RCOG) about the use of water as pain relief in labour.

CQC. (2019) 2018 survey of women's experiences of maternity care. Available at: https://www.cqc.org.uk/sites/default/files/20190424_mat18_statisticalre... [Accessed 18th August 2019]

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. (2012) Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews. (3):CD009234. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009234.pub2... [Accessed 19th July 2019]

Lowth M. (2017) Pain relief in labour. Available at: https://patient.info/pregnancy/labour-childbirth/pain-relief-in-labour [Accessed 19th July 2019]

NHS. (2017) Pain relief in labour. Available at: https://www.nhs.uk/conditions/pregnancy-and-baby/pain-relief-labour/ [Accessed 16th July 2019]

OAA. (2016) Pain relief in labour: how do the options compare. Available at: https://www.labourpains.com/assets/_managed/cms/files/InfoforMothers/Pa... [Accessed 5th July 2019]

OAA. (2019) FAQs Pain relief. Available at: https://www.labourpains.com/FAQ_Pain_Relief [Accessed 5th July 2019]

Sulbaek Andersen MP, Nielsen OJ, Wallington TJ, Karpichev B, Sander SP. (2012) Medical intelligence article: assessing the impact on global climate from general anesthetic gases. Anesth Analg. 114(5):1081-5. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22492189 [Accessed 4th October 2019]

Sustainable Development Unit. (2013) Carbon footprint from anaesthetic gas use. Available at: https://www.sduhealth.org.uk/areas-of-focus/carbon-hotspots/anaesthetic... [Accessed 4th October 2019]

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Labour pain relief: Entonox (gas and air)

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Entonox is a colourless, odourless gas usually made up of half nitrous oxide and half oxygen. Some hospitals add other substances to make it more effective but this might make women more sleepy (OAA, 2019). Nearly 80% of women use Entonox in labour because many find it to be the best option from a range of inhaled pain killers (CQC, 2019).

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

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

When should I get in the pool?

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

How can my birth partner help?

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

What will my midwife do?

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

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

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

What temperature will the birthing pool be?

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

What if I want to get out?

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

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

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

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

Will my midwife suggest I get out of the water?

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

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

What happens if my baby is born in water?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What is TENS?

TENS stands for transcutaneous electrical nerve stimulation. It's a form of pain relief that you can control with a hand-held device.

How does TENS work?

A TENS machine works by sending mild electrical impulses to sticky pads on your lower back. TENS is thought to work as the electrical pulses stimulate nerves that run to the spinal cord and block the transmission of pain (Doswell et al, 2009). This creates a tingling feeling. You can control the strength of the current yourself (OAA, 2019).

TENS might also work by providing a distraction and restoring a sense of control, both of which may lessen the anxiety that can delay the progress of labour(Doswell et al, 2009).

Does TENS work?

A large number of studies have found that women rated their pain similarly, whether using TENS or not (Doswell et al, 2009). But experts are not totally sure whether TENS is effective because more high-quality research about it is needed (Johnson and Jones, 2016).

Some women find it helpful at the start of labour, particularly for backache. While some use only a TENS machine for pain management during labour, it is common to use some other form of pain relief later on in labour (OAA, 2019).

Is TENS suitable for everyone?

Although the electrical pulses used are very small, some people love it, some hate it. It can't be used at the same time as water (shower, bath or birth pool).

There may be additional considerations or monitoring necessary for the use of a TENS machine if a person has a pacemaker fitted. This can be discussed with your health care provider (Badger, 2017).

What do women say about their experiences of TENS?

While most women who use TENS do so to cope with early labour at home, the research has not looked at whether it helps at this point (Doswell et al, 2009). Despite the lack of evidence for its effectiveness, many women said they would be willing to use TENS again in a future labour (Doswell et al, 2009). It's interesting too that women said they were coping with the pain but felt more confident doing so with the distraction of a machine (Doswell et al, 2009).

Does TENS have any side effects?

While some women dislike the sensation or find the device irritating, there are no side effects (OAA, 2016).

Can TENS slow down labour?

TENS does not seem have an effect on the length of labour, interventions in labour, or the wellbeing of mothers and babies (Doswell et al, 2009).

Does TENS affect breastfeeding?

It's not known whether there's any impact on breastfeeding.

Does TENS have any long-term effects?

No.

What happens if I don't like TENS?

If you don't like the sensation or want to try a more effective method such as water instead, it's quick and easy whip off the TENS pads and move on.

Where can I get a TENS machine?

Some hospitals provide TENS machines. If yours doesn't, you can hire or buy one.

Where can I use TENS?

TENS is used by labouring women at home, midwife-led units, travelling in the car, and on the labour ward.

When during labour is TENS used?

It's usually used in early labour, and it can even be used in a car on the way to hospital (OAA, 2016). It is not thought to be beneficial to start using TENS during strong labour (NICE, 2007).

How can my birth partner help with TENS?

The woman will need help to put on the sticky pads. It is a good idea for the birth partner to check the instructions before labour starts, and make sure you have fresh batteries. The pads will mean it's not possible to massage the back, so you can try massaging her head, arms or legs instead if you wish.

Can I use TENS with other pain relief?

As TENS is electrical, you can't use it at the same time as water, and it might interfere with some hospital monitoring. You can use TENS at the same time as Entonox or pethidine/diamorphine.

Would I need any extra procedures if I use TENS?

No.
This page was last reviewed in April 2021.
Further information

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

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

Research from the Royal College of Obstetricians and Gynaecologists (RCOG) about the use of water as pain relief in labour.

Badger J, Taylor P, Swain I.(2017) The safety of electrical stimulation in patients with pacemakers and implantable cardioverter defibrillators: A systematic review. Journal of Rehabilitation and Assistive Technologies Engineering. 4: 1-9.

Dowswell T, Bedwell C, Lavender T, Neilson JP. (2009) Transcutaneous electrical nerve stimulation (TENS) for pain management in labour. Cochrane Database of Systematic Reviews. (2): CD007214. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007214.pub2... [Accessed 5th August 2019]

Johnson M, Jones G. (2016) Transcutaneous electrical nerve stimulation: current status of evidence. Pain Management. 7(1). Available from: https://www.futuremedicine.com/doi/10.2217/pmt-2016-0030 [Accessed 17 March 2021]

NHS. (2015) TENS. Available at: https://www.nhs.uk/conditions/transcutaneous-electrical-nerve-stimulati... [Accessed 17 March 2021]

OAA. (2016) Pain relief in labour: how do the options compare. Available at: https://www.labourpains.com/assets/_managed/cms/files/InfoforMothers/Pa... [Accessed 17 March 2021]

OAA. (2019) FAQs Pain Relief. Available at:  https://www.labourpains.com/FAQ_Pain_Relief. [Accessed 17th March 2021].

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Labour pain relief: TENS machine | Labour & birth articles & support | NCT

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Knowing whether TENS can actually reduce labour pain or is just 'worth a go' could help you to know if you want to find a TENS machine. Here's the lowdown...

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Labour pain relief: epidurals and combined spinal epidurals | Labour & birth articles & support | NCT

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It’s a classic pain reliever for labour but what are the pros and cons of having one? Here we discover some of the lesser-known facts about epidurals.

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What are opioids?

Opioid drugs are painkillers that are usually used in early labour (Lowth, 2017).

The most common type of opioids used during labour are pethidine or diamorphine, although some hospitals use other types (Lowth, 2017; OAA, 2019). Hospitals generally offer one of these types of opioid, but you can ask if you'd prefer a different one.

What do opioids like pethidine do during labour?

They aim to alter your mood during labour so you're more relaxed and can rest or sleep (Lowth, 2017).

How are opioids like pethidine used?

A midwife would usually inject pethidine or diamorphine into your thigh muscle (intramuscular) during labour.

How long does pain relief from opioids like pethidine last?

These opioids take 20 to 30 minutes to work, and each injection lasts for two to four hours (Lowth, 2017; OAA, 2019).

Are opioids good for labour pain relief?

About one in four women use opiates during labour for pain relief (Lowth, 2017). But while they're commonly used, opioids are less effective than Entonox, and their long-term effects are unknown (Sprawson, 2017; OAA, 2019). The advantage of opioids is that they're well known, easily available for midwives and cheap (Sprawson, 2017).

There is some evidence that opioids will give you relief from pain but they might also make you more drowsy, nauseous and sick (Smith et al, 2018). Nobody knows whether pethidine or diamorphine is better for pain relief, or which one women in labour are more satisfied with (Smith et al, 2018).

Are opioids suitable for everyone?

Some women already know that they react poorly to opioids and so would avoid them.

What are women's experiences of pethidine or diamorphine?

Each woman responds in different way to opiates for labour pain. It's good to remember that labour pain is different from the pain of illness or trauma (Sprawson, 2017). Some women find opioids help them feel more relaxed and less worried about the pain (OAA, 2019). Others find it disappointing as a pain reliever and feel less in control (Lowth, 2017; OAA, 2019).

What are the side effects of opioids like pethidine?

Side effects you might get include feeling woozy, sick or forgetful (NHS, 2017). You might need oxygen if your breathing is affected (OAA, 2019). Opioids can also make you too drowsy to push effectively (Lowth, 2017).

Opioids cross the placenta and can affect your baby's breathing. This can mean they have to go to the neonatal unit for help with breathing (NHS, 2017; Moe-Byrne et al, 2018). An opioid antidote called Naxolone can be administered to you and your baby if necessary (Lowth, 2017). But there are concerns about long-term developmental problems for the baby in these cases (Moe-Byrne et al, 2018).

Opioids can also make babies sleepy after birth, which can affect their normal instinctive behaviours (Lowth, 2017).

How do opioids affect labour?

There is no suggestion that injections of opioids lead to further intervention in labour. They might though delay the stomach from emptying, which may be a problem if you later need a general anaesthetic (OAA, 2019).

How do opioids during labour affect breastfeeding?

The effects of opioids on babies' normal instinctive behaviour affects breastfeeding. There's also the risk that if you and your baby are separated because your baby goes to the neonatal unit, that interrupts bonding and hence affects breastfeeding(Moe-Lowth, 2017; NHS, 2017; Byrne et al, 2018).

Does having opioids during labour have any long-term effects?

There are no reported long-term effects.

What happens if I don't like opioids?

If you decide you want to use an opioid, you can ask for the lowest possible dose to see how you react to it. You can always have more but it takes two to four hours to wear off if you don't like it.

Can midwives prescribe opioids such as pethidine?

As midwives can administer opioids, they are widely available. Yet midwives who are caring for women in non-hospital environments, like at a home birth, might be cautious about using opioids because of their impact on babies.

When do women have pethidine during labour?

Opioids should not be given too close to the birth because of the effect on the baby, though it's difficult to know when that will be (Lowth, 2017).

What can my birth partner do to help?

The birth partner can help the woman remain in a good position, comfortable, hydrated and emotionally supported.

Can I have pethidine (or other opioids) during a water birth?

If you've had opioids, you'll be discouraged from using a birth pool until the drugs have worn off. You can use Entonox and TENS alongside opioids.

Would I need any additional procedures?

You'd be offered anti-sickness medicine at the same time as the opioid injection (Lowth, 2017).

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Labour pain relief: opioids - pethidine and diamorphine

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Opioid drugs are painkillers that are usually used in early labour (Lowth, 2017). The most common type of opioids used during labour are pethidine or diamorphine, although some hospitals use other types (Lowth, 2017; OAA, 2019). Hospitals generally offer one of these types of opioid, but you can ask if you'd prefer a different one.

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(birth shown)

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My last client of 2016 dancing her baby... - Birthing in Love, LLC

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My last client of 2016 dancing her baby down through contractions at 6 cm dilated!

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Natural Birth Elizabeth Sings at 10 cm www.serenitybirth.com

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Parto natural na Holanda, nascimento da Helena, - Hypnobirthing

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Oliver's Pain Free Water Birth / HypnoBirth. By Claire Yee, Auckland HypnoBirthing, New Zealand

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Earthside | Everlynn Avigail - Natural Hospital Birth

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What is the third stage of labour?

The third stage of labour is the time between when you have your baby and when the placenta (or afterbirth) comes out (Begley et al, 2011; NICE, 2017).

Once your baby's born, the release of the hormone oxytocin will make the uterus contract and become smaller. This'll make the placenta start to separate.

You will have some bleeding during the third stage of labour as you pass the placenta (Begley et al, 2011).

Active management versus physiological management

Generally, you have two options for how you do the third stage of labour: active management and physiological management. But there's also a third option - mixed management - combining active and physiological approaches (Begley et al, 2011; NICE, 2017).

Physiological management:

It's generally practised in midwife-led units and in home births.

It allows the placenta to be ready to come out mainly by pushing, gravity, contractions and sometimes by nipple stimulation.

It doesn't use oxytocin injections.

The umbilical cord is clamped and cut once it has stopped pulsing or when the placenta has come out.

It can take up to one hour (and shouldn't take more).

Skin-to-skin contact and breastfeeding can help it along, by making your body produce more oxytocin.

It involves sitting in an upright position to encourage the placenta to come out.

Your midwife will monitor your blood loss and keep you and your baby warm.

You'll push the placenta out once it has separated and moved down to your vagina.

It's mostly used if you're at low risk of heavy blood loss.

You can change to active management at any time if needed. (Begley et al, 2011; NICE, 2017)

When the placenta is out, your midwife will clamp and cut the cord. But if you want, you can ask them to wait until it has finished pulsating (RCM, 2013a). Delaying cord clamping for at least a minute has been shown to be beneficial for babies(Science Direct, 2021).

Active management:

Involves an injection of a drug called syntocinon or ergometrine in your thigh soon after your baby's born.

It speeds up the delivery of the placenta - it usually happens within 30 minutes of having your baby. Your midwife will apply some pressure to your belly and pull gently on the umbilical cord to ease the placenta out.

You'll have the umbilical cord cut between one and five minutes after you give birth.

It lowers the risk of heavy blood loss.

It might make you feel sick or vomit, and can increase your risk of high blood pressure.

(Begley et al, 2011; RCM 2013b; NICE, 2017)

Should I have active management or physiological management?

Generally, active management is recommended for all women, to avoid severe haemorrhage. Though this is more of an issue in low-income countries where women are more likely to be poorly nourished, anaemic or have infectious diseases (Begley et al 2015).

If you do go through a haemorrhage though, you'll need to be transferred to a hospital if you're not already there. You'll then be offered treatment that involves:

oxytocin or another drug called ergometrine, which helps the womb to contract and stop the bleeding

your placenta being removed if it hasn't been delivered already

fluids through a drip

oxygen through a facemask.

If the bleeding continues, you'll be given more oxytocin, ergometrine or other drugs. In some cases, an examination under anaesthesia and surgery and/or a blood transfusion might be needed (NICE, 2017).

Retained placenta and problems after birth

If all or some of your placenta has not come out within one hour of you having your baby, this is called a retained placenta.

If that happens to you, you'll need to be put on an intravenous drip. You might also be offered a vaginal examination to see whether you need an operation to remove the placenta. You'll also be offered pain relief (NICE, 2017).

If you do have the placenta removed under anaesthesia, you'll need to have it done within a few hours of the birth to avoid haemorrhage (Weeks, 2001). You'll then need to be transferred to an obstetric unit if you are not already there and might be advised to have an epidural or spinal anaesthetic when the placenta is actually removed (NICE, 2017).
This page was last reviewed in July 2018.
Further information

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

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

Important information on the third stage of labour can be found in NICE guidelines.

Begley CM, Gyte GML, Murphy DJ, et al. (2011) Active versus expectant management of women in the third stage of labour. Cochrane Database Syst Rev.(11):CD007412. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007412.pub3... [Accessed: 13th August 2018]

NICE. (2017) Intrapartum care for healthy women and babies. Available from: https://www.nice.org.uk/guidance/cg190/ifp/chapter/delivering-the-placenta [Accessed: 13th August 2018]

Rabe H, Gyte GML, Díaz‐Rossello JL, Duley L. (2019) Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews. Available from: (9):CD003248. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003248.pub4... [Accessed: 4th October 2019]

RCM. (2013) How to conduct active management of the third stage of labour. Available from: https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to-conduct-active-management-of-the-third-stage-of-labour [Accessed: 13th August 2018]

Weeks AD. (2001) The retained placenta. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704447/] African Health Sciences. 1(1):36-41. [Accessed: 13th August 2018]

Science Direct (2021) A randomized controlled clinical trial on peripartum effects of delayed versus immediate umbilical cord clamping on term newborns [Accessed: 27 August 2021] https://www.sciencedirect.com/science/article/abs/pii/S0301211521002098...
Further reading
Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. (2015) Delivering the placenta with active, expectant or mixed management in the third stage of labour. Cochrane Database Syst Rev. 2015.(3):CD007412. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007412.pub3... [Accessed: 13th August 2018]

Jangsten E, Mattsson LA, Lyckestam I, Hellstrom AL, Berg M. (2011) A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. British J Obst Gynaecol. 118(3):362-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21134105 [Accessed: 13th August 2018]

RCM. (2013) How to promote a physiological third stage of labour. Available from: https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to-promote-a-physiological-third-stage-of-labour [Accessed: 13th August 2018]

Midwife thinking An actively managed placental birth might be the best option for most women https://midwifethinking.com/2015/03/11/an-actively-managed-placental-bi...

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

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The third stage of labour is the time between when you have your baby and when the placenta (or afterbirth) comes out.

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for the baby to get all its blood

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Discover here, in our informative website the benefits and reasons behind the push towards the mindset of "WaitforWhite and Optimal Cord Clamping" in new born babies.

How can it benefit our children?

Why should it become the normal procedure in child birth?

What can you do to ensure a healthy start for your baby?

Find out here the answers to these questions and many more...

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Discover here, in our informative website the benefits and reasons behind the push towards the mindset of "WaitforWhite and Optimal Cord Clamping" in new born babies. How can it benefit our children? Why should it become the normal procedure in child birth? What can you do to ensure a healthy start for your baby?

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Use Your Loaf: The Curse of the Baby Hat - The Birth Hub

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This post was most recently updated on August 19th, 2022It’s deeply ingrained, this habit of putting hats on newborns. Search online for images of newborns and almost all of them are togged up in a woolly hat, for all the world like they are about to go outside for a snowball fight. So why do […]

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9 stages a baby goes through in the first hour or two after birth

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

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

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

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

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

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

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

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

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

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

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

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

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

Babies are warmer.

Babies are calmer.

Babies can hear their mother's heartbeat.

Heart and breathing rates are normalized.

Milk supply may be improved.

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

What To Do in the First Hour with Mother

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

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

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

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

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

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

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Intrapartum care for healthy women and babies | Guidance and guidelines | NICE

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Evidence-based recommendations on intrapartum care for healthy women and babies

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what labour looks like... (calm, not graphic)

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MEET MY BABY! LABOUR AND DELIVERY STORY | POSITIVE HOME BIRTH

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Cochrane Review

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More alternatives to vaginal examination

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Recently I have noticed a few blogs writing about dilation and it's benefits, as well as how to do it in other ways besides simple vaginal exams. This is my take on the subject, modified from the hand out that I have available for my clients.

One of the biggest repeat questions a doula/caregiver can hear during labor and birth is 'how far along am I'. Some women would prefer not to know, some women could care less, and some women desire this knowledge almost habitually.

As with any intervention in labor and birth, cervical checks carry risk. The risks include: increased risk of infection, PROM, false readings (i.e. human error), and regret/disappointment at any 'lack' of dilation.

Regardless of women's reasons for wanting to know their dilation, it is helpful for a doula/care provider to have more than one trick/way of knowing where mom may be, beyond timing contractions.

Some methods that can help a caregiver or doula know how dilated a woman is during her labor include:

Teach self exams

Sounds she makes

Smell of the room/mom

Show

Emotions

The bottom line

Physical Make-Up

Fundal height

Symphysis Crease

Mexican Hot Legs

Pressure

All of these methods are generalities. It is important to remember that women are not textbooks, they are organic, living, evolving organisms that there are many exceptions to every rule. Each of these cannot be applied to all women.

Self Exams

I have found that the best explanation of self exams can be found from Gloria Lemay. It is a practically applicable explanation that gets good results.

"The best way to do it when hugely pregnant is to sit on the toilet with one foot on the floor and one up on the seat of the toilet. Put two fingers in and go back towards your bum. The cervix in a pregnant woman feels like your lips puckered up into a kiss. On a non-pregnant woman it feels like the end of your nose. When it is dilating, one finger slips into the middle of the cervix easily (just like you could slide a finger into your mouth
while puckering for a kiss). As the dilation progresses, the inside of that hole becomes more like a taut elastic band and by 5 cm dilated (5 finger widths) it is a perfect rubbery circle like one of those Mason jar rings that you use for canning, and about that thick." - Gloria Lemay

Sounds of Birth
A non-vaginal indicator that can help to detect progress is notable sounds that a woman makes in labor.

Usually, early labor (0-4cm) means little to no 'birth' noise; mom can talk with little to some effort through a contraction.

Around 4-5cm dilation (for a primip) talk with be rather difficult to near impossible, noises may still be quiet, but consistently open voweled or a resonating hum.

5-7cm will typically be presented with louder noises, near to completely impossible to talk through a contraction, and sounds may become repetitive or staccato.

If a woman is a silent laborer, a good way to get a handle on her vocal indicators is to explain what you are about to do... then wait until a contraction starts, and ask a question that necessitates a sentence-long answer. The way in which she is able or unable to answer you during a contraction should be rather reliable.

Many birth professionals have spoken about the smell of birth.

Birth smells come about around 6-8cm dilation and are a very good indicator of good active labor. When a mom says that she wants to transfer to her place of birth around 6-8cm, I typically will go by smell and mom's emotions.

The active labor smell is not so much the earthy/wet smell of amniotic fluid, and is not the sweet smell on a woman's breath during labor (ever notice a laboring mom's breath always smells sweet?)..

Instead, this smell is deep, dusky (not musky), heavy, familiar... the smell of deep and ancient work. It is something that is hard to explain, but something to definitely be on the look (smell) out for until you have familiarized yourself with it and can use this as a good indicating factor of active labor.

Show
A woman may or may not 'show' any bloody or mucousy discharge at the onset of labor, but blood and mucous often come in copious amounts, usually during contractions, when a woman is around 6-8cm. If a woman's water broke earlier in the labor, you may see a second gush around 6cm.

Emotions
Early labor (1-4cm, oftentimes) often means mom is in the "this is it" stage - happy, excitable, a good sense of humor, perhaps even denial that she is really in labor.

Moving into active labor (4-6cm, oftentimes) often means that mom is still smiley and may even laugh at little things being said between contractions. Moving in and out of conversation as her contractions go and come.

Active labor (5-7cm, oftentimes) generally means she is more irritated at commonplace conversation or people trying to distract her with quips. It may take her quite awhile after a contraction leaves to become 're-acclimated' to the room, or she may choose to simply remain in her birthing space and not interact with the room. (an aside, the room should be acclimating to her, although it is not always the case, unfortunately).

Around transition (usually, 7cmish) even between contractions, a woman can become doubtful, unable to make concrete decisions ("I don't know" in response to questions), or irrational, a good indicator that mom is on the homestretch.

This method can be tricky, though, as this 'emotional mapping' can be skewed from a babies position or a woman's labor make-up.

If it is from baby settling in a 'malpresentation', a mom might experience both an early transition (anywhere from 2cm to 4cm dilation, depending on if she is a primip or multip) and a later transition.

Depending on her labor make-up, some women can have an 'early transition' (4-5cm), especially for long-latent early labor patterns with discomfort disproportionate to her cervical dilation, but it will often still mean rapid dilation to complete.

Bottom/Purple Line
A study conducted and published in the Lancet hypothesized that the purple line that 'grows' up the natal cleft can be a great indicator of cervical dilatation. The line begins at the anal margin at the start of labour and rises like a "mercury thermometer".

When it reaches the top, the woman is fully dilated. The authors propose that an "increase in intrapelvic pressure causes congestion in the ... veins around the sacrum, which, in conjunction with the lack of subcutaneous tissue over the sacrum, results in this line of red purple discoloration".

The best way to describe this is, looking at the anus, a purple line will appear and, throughout labor, move up the natal cleft (butt crack for us laypeople)

The picture shown at right is a fully dilated woman and her purple line.

Physical Make-Up
Many women will find that, as they get very close to the pushing stage, they may exhibit signs similar to the flu. If a mom suddenly feels the urge to vomit or complains of nausea, has a flushed face and feels warm, and/or begins trembling uncontrollably, mom may be at the cusp of second stage. Vomiting alone can be emotions, hormones, or fatigue alone. Flushed face is a good sign of 6-7cm, when noticed alone. And trembling uncontrollably, alone, might mean fatigue or fever. These indicators are most reliable when 2 or all 3 are noticed together.
Other physical indicators of 6cm and beyond:

involuntary curling of toes during contractions, even when the rest of her body is loose and relaxed (6-8cm)

if standing, instead of curling her toes, mom may stand on her toes while leaning over something (6-8cm)

goose bumps on her bottom (buttocks) and upper thighs (9-10cm)

Fundal Height
Anne Frye's Volume II of Holistic Midwifery speaks of the fundal height of being a very reliable indicator of mom's cervical dilation.
When the uterus contracts, it swells upwards and pulls the cervix upward with it, causing more dilation. Around 40 weeks, you can get around 5 finger-breadths of measurement between the fundus and the xyphoid.

As mom dilates, the distance from the xyphoid to the fundus decreases at a rate of about 2cm per fingerbreadths. This way of measuring is not as reliable in primips, but much more reliable in multips. When there is about 1 finger-width or less of space between the fundus and xiphoid, mom is near to at 10 cm dilation.

To do this, have mom (or partner) 'mark' her measurement at the first thought of labor. Taking into consideration her starting point (from prior VEs (Vaginal Exams)), use this as a start point.

Unfortunately, this assessment during labor must be done at the height of a contraction and mom must be on her back. Using the chart below, determine fingerbreadths (fb) between the fundus and xiphoid:
Symphysis Crease
Late dilation can be measured by watching the symphysis crease. It's visible mostly in mom's who have lower BMI prepregnancy. As labor progresses and babies shoulder's descend along with dilation, a line/crease will become visible directly above (parallel to) the symphysis. It will become wider latitudinally as labor progresses.

Around transition, it will be about 3/4 of the way across. If the line is nearly all the way across, mom is most likely pretty close to, or already fully, dilated and will probably start pushing soon.

To do this, check right above mom's symphysis (pubic bone). If there is a line at all, mom is probably at least 5cm. If you are working with a woman who is intent on laboring at home as long as possible, the crease may be a good indicator for her labor, a drawback is that it can also mean 'too late'.

Another drawback to this is if baby is riding high throughout the early and active labor stage (aka a 'late descender').

As the birthing woman's body works harder, blood is withdrawn from the extremities to be utilized by the womb. Thus, the woman's legs get progressively colder from the ankle to the knee as labor progresses. At the start of birth, the whole leg will be warm. At around 5cm, the leg will be coldre from the ankle to around mid-calf than it is above the calf. Once the whole leg feels coldre up to the knee, then the urge to push should shortly follow.

This technique is less reliable if the woman is having an epidural, as the drugs will also affect the temperature of the hands and legs. If a woman is birthing in water then she'd need to be on dry land for around 20 minutes to allow the temperature in her legs to be measured accurately. -Kath Harbisher

As baby descends, pressure will be felt at different levels on her back. This will not necessarily give dilation information, but will help in determining position/station of baby within the pelvic outlet. This pressure will move from the rim of the pelvis all the way down onto the coccyx (tailbone).

As doulas can tell you, as mom continues to dilate, and baby continues to move down the pelvis, the pressure she feels will go lower. This is why back massages turn into butt massages turn into tailbone massages. :)

By the time that mom is 8-10cm and 0 to +1 station, the small rectangular spot of mom's buttocks (tailbone area) will bow outward as her pelvis makes room for babies decent. This usually means that, if you are at home and mom was planning a hospital or birth center birth, you very well may have waited too long.

Another indicator is that, if mom is feeling pressure between her legs, vomits, and her water breaks simultaneously, she is probably 7-8cm or more.

A final indicator is, regardless of dilation, if a mom is passing stool involuntarily with her contractions, whether she has the urge to push or not, she is either holding a posterior baby, fully dilated and about to start pushing, or baby is at a low station (more common without full dilation in multips).

In Conclusion
Dilation of the cervix can tell us how far open you are, but not how close you are to the destination of birthing your baby. Listening to your body and the cues it gives can help us know where you are at in your journey though. Some women's journeys take them through jogs and shortcuts, while others are mountainous day-hikes.

More than anything else, these tools can help women to plan their next steps on their birthing journeys; when to move to their expected place of birth, when to enter the birthing pool, what their labor pattern might indicate, what is true labor vs what is practice labor.

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Dilation - How To Check Without Checking

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Recently I have noticed a few blogs writing about dilation and it's benefits, as well as how to do it in other ways besides simple vaginal exams. This is my take on the subject, modified from the hand out that I have available for my clients.

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communicating your preferences

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What is a birth plan?

A birth plan is a way for you to communicate your wishes to the midwives and doctors who care for you in labour. It tells them about the type of labour and birth you'd like to have, what you want to happen, and what you want to avoid (NHS 2018a).

A birth plan is not set in stone. It needs to be flexible and acknowledge that things may not go according to plan (NHS 2018a). For example, you may plan to have a water birth, but find there's no birth pool available on the day you go into labour (NHS 2018a). Or you may want to avoid an induction or c-section, only to find out that this is safer for your baby.

Try to think of your birth plan more as a "birth wishlist". It lays down your hopes for the birth, and provides a useful guideline for your midwife or doctor. Researching a birth plan is also a great way to learn more about what to expect on the day. But you and your birth partner should still prepare yourselves for the possibility that you may need or want to make some adjustments on the day (NHS 2018a).

When the time comes, your midwife or obstetrician will recommend what they think is the best and safest option for you and your baby (NHS 2018a). You can also change your mind about anything on your birth plan at any time (NHS 2018a).

You don't have to write a birth plan, but if you do, your midwife will help you (NHS 2018a). If you're not sure about a certain procedure, or if you prefer to keep your options open, talk to your midwife and then write it down.

Your birth plan is personal to you and should reflect your wishes and preferences (NHS 2018a). You may want to add details about your medical history, but your midwife will have your maternity notes, so will be aware of your circumstances. It's worth taking into account what's available at your local hospital or birth centre (NHS 2018a) when you write your plan.

What research can I do before I start writing my birth plan?

Gather as much information as you can before you start (Which nd):

Join your local antenatal classes (NHS 2018b, Which nd). Your midwife should offer you free NHS classes (NHS 2018b), or there are also private classes available through the NCT. You can also sign up for BabyCentre's free online antenatal classes in our community.

If you know anyone who's given birth recently, ask them about their experiences (NHS 2018b, Which nd). If possible, talk to mums who have given birth in different places, such as a hospital, birth centre or at home. That way, you'll learn all about the different options, helping you work out what's best for you.

Talk to your partner or the person who will be your birth partner (NHS 2018a). Make sure they fully understand the type of labour and birth you'd like to have. How do they see their role?

Of course, you can also find out more about your options, and what to expect on the day, by reading all about labour and birth on BabyCentre.

Once you've spoken to a few people and researched your choices, jot your birth wishes down on a piece of paper, as they come to mind. You can tidy them up later.
Your midwife may give you a special form for your birth plan, or there may be room in your maternity notes (NHS 2018a). Keep a copy of your birth plan with your maternity notes, and try to keep them nearby at all times in late pregnancy (NHS 2018a). That way, you'll know you have them on hand when you go into labour.

If you are having a planned c-section, you can still write a birth plan (Tommy's 2019). Even if you're planning on having a vaginal birth, it's a good idea to think about what might happen if a c-section ends up being the safest thing for your baby (Which nd). Read more about caesarean birth plans.

What should I include in my plan?

It's completely up to you how much information you want to include (Which nd). You could just jot down a few notes about the things that are most important to you, or put together a more detailed plan (Which nd). Ideally, aim for just one or two pages, but try not to worry if it does end up longer than this (Which nd).

Here are some headings you could use in your birth plan. Choose which ones which are important to you, and feel free to add extra headings for anything else that comes to mind.

Where to give birth

Your birth options will depend on what's available in your area, and how your pregnancy is going (NHS 2018a). In general, there are three main choices available:

Your midwife can give you more information about your options, and help you decide which is best for you (NHS 2018a). This birth choice tool can also help you find out what's available.

Your birth partner

Say who you want to have with you in labour. Do you want this person (or people) to stay with you all the time, or are there certain procedures or stages when you'd prefer them to leave the room? Would you like to talk to your birth partner in private about any interventions that are suggested? And would you like your birth partner to stay with you if you need an assisted birth or a c-section (NHS 2018a)?

Positions for labour and birth

Mention which positions you would like to use during labour and for your baby's birth. Also say how active you would like to be. Would you like to remain upright and mobile for as long as possible? Or perhaps you'd prefer to be upright in bed with your back propped up with pillows? Or you could specify that you want to lie on your side, be kneeling on all fours or standing or squatting (NHS 2018a).

Pain relief

Say what kinds of pain relief you would like to use, if any, and in what order. For example, you may prefer to try gas and air before an epidural.

As well as medical pain relief, you could also mention other therapies and techniques that are often used to help with labour pain, such as:

It's also worth noting down if you plan to use hypnobirthing techniques to help you cope with labour pains (Tommy's 2018).

If there are any types of pain relief you'd prefer to avoid using, make sure you write them down, too.

Speeding up labour

If your labour slows down, or is proving to be very long, do you want your midwife to break your waters or give you hormones to speed it up? Or would you prefer to wait and see what happens naturally (WHO 2014)?

Birth pool

If your hospital or midwife-led unit has a birth pool, or if you're hiring one to use at home, write down whether you want to use it for pain relief or to give birth in, or both (NHS 2018a).

Other equipment

Your hospital or birth centre may have wall bars, birth balls, mats or beanbags for use during labour. Or you may need to bring equipment in from home. Make a note of the type of equipment you would like to use in your plan (NHS 2018a).

Monitoring your baby's heart rate

If your pregnancy is straightforward your midwife will monitor your baby's heartbeat about once every 15 minutes (then every five minutes once you're in the pushing stage (Payne 2015)), using a handheld device (intermittent monitoring) (Which nd).

If there are any concerns about your health or the health of your baby, you may be offered continuous monitoring at a hospital instead (Which nd). Talk to your midwife about which option is right for you, and note your decision in your birth plan (NHS 2018a)

Episiotomy

If you're at risk of experiencing a severe tear as your baby is born, your midwife can make a small cut in the skin around your vagina (episiotomy), to reduce further tearing (NHS 2018a, Which nd). Episiotomies are also sometimes used if your baby is in distress and needs to be born quickly (NHS 2018a). Talk to your midwife about whether you're happy to have an episiotomy if necessary, or you'd rather try to avoid one if at all possible (Which nd).

Cord clamping

After your baby is born, the umbilical cord will need to be clamped and cut. This used to happen immediately after the birth, but these days it's recommended to wait at least one to five minutes, or until the cord stops pulsing (delayed cord clamping) (Tommy's 2017). This allows more blood to flow to your baby, giving him extra iron and boosting his immune system (Tommy's 2017).

You can also say whether you'd like your partner to cut the cord (Which nd).

Third stage (delivery of the placenta)

Once your baby is born, your midwife may offer you an injection to speed up the delivery of the placenta, particularly if you're in a hospital (NCT 2018). This is called a managed third stage. You can choose to have the injection no matter where you give birth, or you may prefer to have a natural (physiological) third stage without drugs (NCT 2018). Talk to your midwife about which option might be right for you, and write your choice in your birth plan (NHS 2018a).

Skin-to-skin contact

You may wish for your baby to be placed directly onto your tummy after the birth, so you can see and touch him straight away. Not only is this great for bonding, but it can also help to calm your baby, regulating his heart rate, breathing and temperature (Unicef nd). However, some women prefer for a midwife to clean their baby and wrap him in a blanket before meeting him for the first time (NHS 2018a).

Feeding your baby

Be clear about whether you want to breastfeed or formula-feed, or both (NHS 2018a). If you do plan to breastfeed, you could add whether you'd like help getting things started (Which nd). Also be clear about whether your breastfed baby is allowed to have any bottles of formula. If you definitely don't want him to have formula, say so (Which nd).

Vitamin K

Once your baby is born, your midwife will offer to give him an injection of vitamin K. This vitamin is important for blood clotting. All babies are born with low levels of vitamin K and some babies don't have enough to help their blood clot (NHS 2018a). That's why doctors recommend that all newborn babies have the injection. If you don't want your baby to have the injection, it's possible for him to have vitamin K by mouth instead, though he'll need more doses (Tommy's 2019).

Medical professional training

In some cases, you may be asked whether you're happy to have a trainee midwife, doctor or nurse observe your labour (NHS 2018a). This is an essential part of their training, and they'll always be supervised by a more senior member of staff, but you're completely free to say in your birth plan if you don't want them to attend when you give birth (NHS 2018a).

What if I have particular needs?

You may have special requirements that you want to mention in your birth plan. If you have a disability, write about the help you'll need in labour (NHS 2018a). Say whether there is any special equipment that would assist you.

If English isn't your first language and you need an interpreter, say so. Also let your midwife know if you need a sign language interpreter (NHS 2018a).

Include any religious requirements, such as customs you'd like to be carried out when your baby is born (NHS 2018a). Or you might require a special diet during your hospital stay (NHS 2018a). Write all of these things down. Health professionals are committed to being culturally sensitive and treating you as an individual.

I've written my plan. What happens next?

Show your birth plan to your midwife and ask her to go through it with you (NHS 2018a) during one of your antenatal appointments. Your 36-week appointment is often the ideal time for this.

Discussing your plan with your midwife will give you the chance to ask questions and find out more about what will happen when you go into labour. Also, by listening to your preferences, your midwife will get to know you better and understand what's important to you (NHS 2018a).

Be sure to go through your plan with your birth partner, too (Tommy's 2019). When you're in labour, your midwife might not have time to read your birth plan very thoroughly (Which nd). If your birth partner knows your wishes, he can advocate for you and help you get the birth experience you want (Tommy's 2019).

Though a birth plan is helpful, labour and birth are unpredictable. Your midwife or doctor may need to recommend a different course of action at any time, which may not be what you had originally hoped for. But any changes will always be in the best interests of you and your baby (NHS 2018a).

More on preparing for labour

References

NCT. 2018. Third stage of labour: delivering the placenta and clamping the umbilical cord. NCT, Labour & birth. www.nct.org.uk [Accessed June 2019]

NHS. 2018a. How to make a birth plan. NHS, Health A-Z. www.nhs.uk [Accessed July 2019]

NHS. 2018b. Antenatal classes. NHS, Health A-Z. www.nhs.uk [Accessed July 2019]

Payne J. 2015. Intrapartum fetal monitoring. Patient, Professional Articles. patient.info [Accessed July 2019]

Tommy's. 2017. Delayed cord clamping. Tommy's, Pregnancy information. www.tommys.org [Accessed December 2019]

Tommy's. 2018. Hypnobirthing. Tommy's, Pregnancy information. www.tommys.org [Accessed July 2019]

Tommy's. 2019. Making your birth plan. Tommy's, Pregnancy information. www.tommys.org [Accessed July 2019]

Unicef. nd. Skin-to-skin contact. United Nations International Children's Emergency Fund, The Baby Friendly Initiative. www.unicef.org.uk [Accessed July 2019]

Which. nd. Your birth plan. Which? Birth Choice. www.which.co.uk [Accessed July 2019]

WHO. 2014. WHO recommendations for augmentation of labour. Word Health Organisation. www.who.int [Accessed July 2019]

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A birth plan is a way to set out your wishes for labour and birth. Find out more about writing your birth plan, including examples of the kinds of things to include, and how your midwife can help. - BabyCentre UK

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Sara Wickham

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Group B Strep resources - Dr Sara Wickham

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

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What is the issue?

Many women deliver by caesarean section (CS) nowadays. The proportion of women who deliver by CS ranges from 15% to over 50%, in some countries. After a CS it is common for the bowel to stop working for several hours or days. Although this usually resolves by itself in a few days, it may be very uncomfortable. The retained gases and stools can cause the mother's belly to become swollen and painful with cramps and she may feel nauseated and vomit so she is not able to eat. She may need additional medications to ease these symptoms and her hospital discharge may be delayed. The use of medications that relieve pain during labour and painkillers following the surgery can also delay bowel function.

Although early feeding after a CS can stimulate the gut, it could also lead to vomiting. That is why many obstetricians still withhold food until bowel sounds are detected and there is passage of gas, or flatus. Chewing gum can help the bowels to function again earlier, as shown with other types of surgeries. We wanted to see if it also worked after a CS. Chewing gum in the first 24 hours after the surgery is a simple and cheap intervention.

What evidence did we find?

We included randomised controlled studies published up to June 2016.

We found 17 studies, with 3149 women who had just delivered by CS. In these studies, a group of women chewed gum and a second group did not, receiving usual care. The studies were conducted in nine countries (mostly low- to middle-income countries) and were different in many aspects. For instance, some studies included only women having their first baby and others included women with a previous CS; some studies included only elective (pre-scheduled) CS and others also included emergency CS. The way that gum was given also differed in the studies; in some the women started chewing gum right after the CS and in others they waited for up to 12 hours. Also, the women could not be blinded to receiving the gum. The combination of the results (in a meta-analysis) of these studies showed that the women who chewed gum after a CS had an earlier return of their bowel function. On average, they passed gas seven hours earlier (13 studies, 2399 women). This effect was consistent for first versus repeat CS, time spent chewing gum per day, early feeding versus nothing by mouth until the return of intestinal function, elective versus non-elective or emergency CS, and length of time after CS when gum-chewing was initiated. The quality of the evidence for this outcome was very low. The women chewing gum were at least half as likely to have 'ileus' (a combination of symptoms such as bloating, cramping, nausea, vomiting and inability to defecate) than the women who did not chew gum (four studies, 1139 women, low-quality evidence). Gum chewing reduced the time to first defecation to about nine hours earlier (11 studies, 2016 women, very low-quality evidence) and the time to hospital discharge by some eight hours (seven studies, 1489 women). Only three out of 925 women complained about having to chew gum and there were no reports of adverse effects associated with gum-chewing (eight studies, 925 women, low-quality evidence). None of the studies assessed women's satisfaction in relation to chewing gum.

The overall quality of the evidence was low to very low, mostly due to lack of blinding of the participants (the women knew they were chewing gum) and heterogeneity between the studies.

What does this mean?

The available evidence suggests that gum-chewing in the first 24 hours after a CS is a well-tolerated simple, low-cost, safe and easy intervention that enhances early recovery of bowel function, improves maternal comfort and potentially reduces hospital costs. Further research is necessary to establish the optimal regimen of gum-chewing (when to start, number and duration of sessions per day) to enhance bowel function recovery and to assess potential adverse effects and women's satisfaction with this intervention.

This review found 17 randomised controlled trials (involving 3149 women). We downgraded the quality of the evidence for time to first passage of flatus and of faeces and for adverse effects/intolerance to gum chewing because of the high risk of bias of the studies (due to lack of blinding and self-report). For time to first flatus and faeces, we downgraded the quality of the evidence further because of the high heterogeneity in these meta-analyses and the potential for publication bias based on the visual inspection of the funnel plots. The quality of the evidence for adverse effects/tolerance to gum chewing and for ileus was downgraded because of the small number of events. The quality of the evidence for ileus was further downgraded due to the unclear risk of bias for the assessors evaluating this outcome.

The available evidence suggests that gum chewing in the immediate postoperative period after a CS is a well tolerated intervention that enhances early recovery of bowel function. However the overall quality of the evidence is very low to low.

Further research is necessary to establish the optimal regimen of gum-chewing (initiation, number and duration of sessions per day) to enhance bowel function recovery and to assess potential adverse effects of and women's satisfaction with this intervention. New studies also need to assess the compliance of the participants to the recommended gum-chewing instructions. Future large, well designed and conducted studies, with better methodological and reporting quality, will help to inform future updates of this review and enhance the body of evidence for this intervention.

Read the full abstract...

Caesarean sections (CS) are the most frequent major surgery in the world. A transient impairment of bowel motility is expected after CS. Although this usually resolves spontaneously within a few days, it can cause considerable discomfort, require symptomatic medication and delay hospital discharge, thus increasing costs. Chewing gum in the immediate postoperative period is a simple intervention that may be effective in enhancing recovery of bowel function in other types of abdominal surgeries.

To assess the effects of chewing gum to reduce the duration of postoperative ileus and to enhance postoperative recovery after a CS.

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 June 2016), LILACs (20 June 2016), ClinicalTrials.gov (20 June 2016), WHO International Clinical Trials Registry Platform ( ICTRP) (20 June 2016) and the reference lists of retrieved studies.

All randomised controlled trials comparing chewing gum versus usual care, for women in the first 24 hours after a CS. We included studies published in abstract form only.

Quasi-randomised, cross-over or cluster-randomised trials were not eligible for inclusion in this review.

Data collection and analysis:

Two review authors independently selected the studies for inclusion, extracted data and assessed the risk of bias following standard Cochrane methods. We present dichotomous outcome results as risk ratio (RR) with 95% confidence intervals (CI) and continuous outcome results as mean differences (MD) and 95% CI. We pooled the results of similar studies using a random-effects model in case of important heterogeneity. We used the GRADE approach to assess the overall quality of evidence.

We included 17 randomised trials (3149 participants) conducted in nine different countries. Seven studies (1325 women) recruited exclusively women undergoing elective CS and five studies (833 women) only included women having a primary CS. Ten studies (1731 women) used conventional feeding protocols (nil by mouth until the return of intestinal function). The gum-chewing regimen varied among studies, in relation to its initiation (immediately after CS, up to 12 hours later), duration of each session (from 15 to 60 minutes) and number of sessions per day (three to more than six). All the studies were classified as having a high risk of bias due to the nature of the intervention, women could not be blinded and most of the outcomes were self-reported.

Primary outcomes of this review: for the women that chewed gum, the time to passage of first flatus was seven hours shorter than those women in the 'usual care' control group (MD -7.09 hours, 95% CI -9.27 to -4.91 hours; 2399 women; 13 studies; random-effects Tau² = 14.63, I² = 95%, very low-quality evidence). This effect was consistent in all subgroup analyses (primary and repeat CS, time spent chewing gum per day, early and conventional feeding protocols, elective and non-elective CS and time after CS when gum-chewing was initiated). The rate of ileus was on average over 60% lower in the chewing-gum group compared to the control (RR 0.39, 95% CI 0.19 to 0.80; 1139 participants; four studies; I² = 39%, low-quality evidence). Tolerance to gum-chewing appeared to be high. Three women in one study complained about the chewing gum (but no further information was provided) and none of the studies reported adverse effects (eight studies, 925 women, low-quality evidence).

Secondary outcomes of this review: the time to passage of faeces occurred on average nine hours earlier in the intervention group (MD -9.22 hours, 95% CI -11.49 to -6.95 hours; 2016 participants; 11 studies; random-effects Tau² = 12.53, I² = 93%, very low-quality evidence). The average duration of hospital stay was shorter in the intervention compared to the control group (MD -0.36 days, 95% CI -0.53 to -0.18 days; 1489 participants; seven studies; random-effects Tau² = 0.04, I² = 92%). The first intestinal sounds were heard earlier in the intervention than in the control group (MD -4.56 hours, 95% CI -6.18 to -2.93 hours; 1729 participants; nine studies; random-effects Tau² = 5.41, I² = 96%). None of the studies assessed women's satisfaction in relation to having to chew gum. The need for analgesia or antiemetic agents did not differ between the intervention and control groups (average RR 0.50, 95% CI 0.12 to 2.13; 726 participants; three studies; random-effects Tau² = 0.79, I² = 69%).

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Does chewing gum after a caesarean section lead to quicker recovery of bowel function?

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What is the issue? Many women deliver by caesarean section (CS) nowadays. The proportion of women who deliver by CS ranges from 15% to over 50%, in some countries. After a CS it is common for the bowel to stop working for several hours or days.

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Here's the guidance...

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Coronavirus (COVID19): Advice for parents

Everyone should follow the government advice on coronavirus:

This guidance was published on 11 May 2020. As this is a fast-moving situation, we will be reviewing and updating the guidance as it changes. Please keep checking this page for updates.

Yes. Newborn screening appointments are continuing as normal. You should go to your appointments unless you, your child or someone you live with has symptoms of coronavirus.

If you have symptoms of possible coronavirus infection, you should contact your GP or Health Visitor to postpone appointments until you have stopped self-isolating.

Yes. Routine vaccinations for babies and pre-school children are continuing as normal. You should go to your appointments unless you, your child or someone you live with has symptoms of coronavirus.

If you have symptoms of possible coronavirus infection, you should contact your GP or Health Visitor to postpone appointments until you have stopped self-isolating.

Yes. There is currently no evidence to suggest that coronavirus can be carried or passed on in breast milk. The well-recognised benefits of breastfeeding outweigh any potential risks of transmission of coronavirus through breastmilk.

The main risk of feeding your baby is the close contact between you and your baby. A discussion about the risks and benefits of breastfeeding should take place between you and your family and your maternity team.

Find more information for women with suspected or confirmed coronavirus who have recently given birth from the Royal College of Obstetricians and Gynaecologists

If you have suspected, or confirmed coronavirus, wash your hands (for at least 20 seconds) before touching your baby and try to avoid coughing or sneezing on them while they feed. Please take care not to fall asleep with your baby.

If you're feeling unwell, it may be easier to carry on breastfeeding (rather than expressing) during this stressful time. Alternatively, if you have been expressing your breast milk, you may prefer someone else (who is well) to bottle feed your baby.

Breast milk provides natural (germ killing) antibodies that help your baby fight illness and infections - it's also the best source of nutrition for them.

We recommend babies are exclusively breastfed until they are around 6 months old - then breastfed alongside solid foods (until they are 1 year at least).

Have a look at more benefits of breastfeeding on Start4Life.

If you have suspected, or confirmed coronavirus, make sure you wash your hands (for at least 20 seconds) before touching your baby. When you are feeding your baby - try to avoid coughing or sneezing on them.

Expressing breast milk: If you're expressing your breast milk, always wash your hands before handling your breast pump and bottles. Have a look at the Start4Life guide to expressing breast milk.

Sterilising equipment: If your baby is having formula or expressed milk, make sure you sterilise the equipment carefully before each use. You should not share bottles or a breast pump with anyone else. Have a look at the NHS guide to sterilising bottles.

Making up formula feeds: When making formula feeds, carefully follow the manufacturer's instructions. Use the right amount of formula and water - ensuring the water is hot enough (at least 70C) to kill any germs in the powder. Have a look at the NHS step by step guide to making up formula.

Because we're indoors a lot of the time, we might not be getting enough vitamin D from sunshine. You should consider taking a vitamin D supplement - available from most pharmacies, supermarkets and other retailers. You just need 10mcg (micrograms) a day - this applies to adults and children.

From birth, all breastfed babies should be given a daily supplement of vitamin D (8.5 to 10mcg). However, if your baby is having more than 500ml (about a pint) of first infant formula a day, they do not need a supplement because formula is already fortified with vitamin D.

There have been some news reports about vitamin D reducing the risk of coronavirus. However, there is no evidence for this. Find out more about vitamin D

If you can't get hold of your usual first infant formula, don't worry - you can switch to another brand. They are all very similar and contain the right nutrients for your baby because all brands have to meet strict legal standards. Remember, follow-on formula is not suitable for babies under 6 months.

You can find lots of fun activity ideas for 0-5 year olds from Hungry Little Minds and the BBC's Tiny Happy People

There are lots of things you can do with your child to help them learn, such as:

chat to them about everything and anything - take turns to babble or talk

play make believe games together

read together - help them name pictures in the book

sing songs with actions

If you or someone you know needs help and advice - there is support available from Safe Lives and GOV.UK.

With more time being spent at home, it's important to ensure that your home is safe so that accidents are prevented.

Read about staying safe and preventing accidents in the home:

NHS tips to prevent your baby or toddler from some of the most common accidents in the home.

ROSPA advice on keeping children safe at home.

Safe sleeping advice from the Lullaby Trust.

Soothing crying babies can be challenging, particularly when families are spending a lot of time together in the home. ICON have some useful tips for parents. If you are worried about your child or family, contact your health visitor for guidance and support.

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Everyone should follow the government advice on coronavirus. Have a look at our Q&A's for pregnant women and parents on Start4Life

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Skip to main content Home Baby Coronavirus (COVID19): Advice for parents Everyone should follow the government advice on coronavirus: This guidance was published on 11 May 2020. As this is a fast-moving situation, we will be reviewing and updating the guidance as it changes. Please keep checking this page for updates.

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the evidence

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Almost everyone-including doctors, midwives, and online due date calculators-uses Naegele's rule (listen to the pronunciation here to figure out an estimated due date (EDD).

Naegele's rule assumes that you had a 28-day menstrual cycle, and that you ovulated exactly on the 14th day of your cycle (Note: some health care providers will adjust your due date for longer or shorter menstrual cycles).

To calculate your EDD according to Naegele's rule, you add 7 days to the first day of your last period, and then count forward 9 months (or count backwards 3 months). This is equal to counting forward 280 days from the date of your last period.

For example, if your last menstrual period was on April 4 you would add seven days (April 11) and subtract 3 months = an estimated due date of January 11.

Another way to look at it is to say that your EDD is 40 weeks after the first day of your last period.

In cases where the date of conception is known precisely, such as with in vitro fertilization or fertility tracking where people know their ovulation day, the EDD is calculated by adding 266 days to the date of conception (or subtracting 7 days and adding 9 months). This increases the accuracy of the EDD because it no longer assumes a Day 14 ovulation based on the first day of the last menstrual period.

But where did Naegele's rule come from?

In 1744, a professor from the Netherlands named Hermann Boerhaave explained how to calculate an estimated due date. Based on the records of 100 pregnant women, Boerhaave figured out the estimated due date by adding 7 days to the last period, and then adding nine months (Baskett & Nagele, 2000).

However, Boerhaave never explained whether you should add 7 days to the first day of the last period, or to the last day of the last period.

In 1812, a professor from Germany named Carl Naegele quoted Professor Boerhaave, and added some of his own thoughts. (This is how Naegele's rule got its name!) However, Naegele, like Boerhaave, did not say when you should start counting-from the beginning of the last period, or the last day of the last period.

His text can be interpreted one of two ways: either you add 7 days to the first day of the last period, or you add 7 days to the last day of the last period.

As the 1800s went on, different doctors interpreted Naegele's rule in different ways. Most added 7 days to the last day of the last period.

However, by the 1900s, for some unknown reason, American textbooks adopted a form of Naegele's rule that added 7 days to the first day of the last period (Baskett & Nagele, 2000).

And so this brings us to today, where almost all doctors use a form of Naegele's rule that adds 7 days to the first day of your last period, and then counts forward 9 months-a rule that is not based on any current evidence, and may not have even been intended by Naegele.

What is the most accurate way to tell how far along you are?

Doctors started using ultrasound in the 1970s. Soon after, ultrasound measurement replaced last menstrual period (LMP) as the most reliable way to define gestational age (Morken et al., 2014).

A large body of evidence shows that ultrasounds done in early pregnancy are more accurate than using LMP to date a pregnancy. In a 2015 Cochrane review, researchers combined the results from 11 randomized clinical trials that compared routine early ultrasound to a policy of not routinely offering ultrasound (Whitworth et al. 2015).

The researchers found that people who had an early ultrasound to date the pregnancy were less likely to be induced for a post-term pregnancy.

In other words, using the LMP to estimate your due date makes it more likely that you will be mislabeled as "post-term" and experience an unnecessary induction.

In a large observational study that enrolled more than 17,000 pregnant people in Finland, researchers found that ultrasound at any time point between 8 and 16 weeks was more accurate than the LMP. When ultrasound was used instead of a "certain" LMP (in other words, the mother is "certain" about the date she had her last period), the number of "post-term" pregnancies decreased from 10.3% to 2.7% (Taipale & Hiilesmaa, 2001).

Why is LMP less accurate than using ultrasound?

There are several reasons why the LMP is usually less accurate than an ultrasound (Savitz et al., 2002; Jukic et al., 2013; ACOG, 2017). LMP is less accurate because it can have these problems:

People can have irregular menstrual cycles, or cycles that are not 28 days

People may be uncertain about the date of their LMP

Many people do not ovulate on the 14th day of their cycle

The embryo may take longer to implant in the uterus for some people

Research indicates that some people are more likely to recall a date that includes the number 5, or even numbers, so they may inaccurately recall that the first day of their LMP has one of these numbers in it.

What is the best time to have an ultrasound to determine gestational age?

In a 2013 study, researchers grouped ultrasound scans by <7 weeks, 7-10 weeks, 11-14 weeks, 14-19 weeks, and 20-27 weeks (Khambalia et al., 2013).

The authors found that the most accurate time to perform an ultrasound to determine the gestational age was 11-14 weeks. About 68% of people gave birth ±11 days of their estimated due date as calculated by ultrasound at 11-14 weeks. This was a more accurate result than any of the other ultrasound scans, and more accurate than the LMP.

The accuracy of the ultrasound saw a significant decline starting at about 20 weeks. Using an estimated due date from either the LMP or an ultrasound at 20-27 weeks led to a higher rate of pre- and post-term births.

Should a due date be changed based on a third trimester ultrasound?

In the Listening to Mothers III study, one in four mothers (26%) reported that their care provider changed their estimated due date based on a late pregnancy ultrasound. For 66% of the mothers, the estimated due date was moved up to an earlier date, while for 34% of the mothers, the date was moved back to a later date (Declercq et al., 2013).

Ultrasounds in the third trimester are less accurate than earlier ultrasounds or the LMP at predicting gestational age. Ultrasounds in the third trimester are not as accurate because they are measuring the size of the baby and comparing him or her to a "standard" sized baby. All babies are about the same size early in pregnancy. But if your baby will be larger than average, it will be perceived as "closer to done" when the ultrasound is done, and your due date will be moved up (incorrectly).

The reverse is also true for babies that will be smaller than average at term-their due date might be moved to a later date. This could be risky if the baby is experiencing growth restriction, as growth-restricted babies have a higher risk of stillbirth towards the end of pregnancy. Because of these problems with third trimester ultrasounds, the American College of Obstetricians and Gynecologists states that due dates should only be changed in the third trimester in very rare circumstances (2017).

They suggest that the due date should only be changed after a third trimester pregnancy ultrasound if 1) it is the pregnant person's first ultrasound, and 2) it is more than 21 days different than the due date suggested by the LMP (ACOG, 2017).

How long is a normal pregnancy? Is it really 40 weeks?

In the U.S. and other Western countries, induction is common at or even before 40 weeks, so it is impossible to know exactly what percentage of people today would naturally go into labor and give birth before, on, or after their estimated due date.

In the past, researchers figured out the average length of a normal pregnancy by looking at a large group of pregnant people, and measuring the time from ovulation (or the last menstrual period, or an ultrasound) until the date the person gave birth-and calculating the average. However, this method is wrong and does not give us accurate results.

Why is this method wrong?

This method does not work because many people are induced when they reach 39, 40, 41, or 42 weeks.

If you do include these induced people in your average, then you are including people who gave birth earlier than they would have otherwise, because they were not given time to go into labor on their own.

But this puts researchers in a bind, because if you exclude a person who was induced at 42 weeks from your study, then you are ignoring a pregnancy that was induced because it went longer-and by excluding that case, you artificially make the average length of pregnancy too short.

So how can we deal with this problem?

Researchers today use a method called "survival analysis" or "time to event analysis." This is a special method that allows you to include all of these people in your study, and still get an accurate picture of how long it takes the average person to go into spontaneous labor. There have been two studies that measured the average length of pregnancy using survival analysis:

Study finds that estimated due date is 3 to 5 days AFTER 40 weeks

In a very important study published in 2001, Smith looked at the length of pregnancy in 1,514 healthy women whose estimated due dates, as calculated by the first day of the last menstrual period, were perfect matches with estimated due dates from their first trimester ultrasound (Smith, 2001a).

The researchers found that 50% of all women giving birth for the first time gave birth by 40 weeks and 5 days, while 75% gave birth by 41 weeks and 2 days.

Meanwhile, 50% of all women who had given birth at least once before gave birth by 40 weeks and 3 days, while 75% gave birth by 41 weeks.

This means that for both first-time and experienced mothers in Smith's study, the traditional "estimated due date" of 40 weeks was wrong!

The actual pregnancy was about 5 days longer than the traditional due date (using Naegele's rule) in a first-time mother, and 3 days longer than the traditional due date in a mother who has given birth before.

Study finds that estimated due date should be closer to 40 weeks and 5 days

In 2013, Jukic et al. used survival analysis to look at the normal length of a pregnancy. This was a smaller study-there were only 125 healthy women, and they all gave birth between the years 1982 and 1985. However, this was also an important study, because researchers followed the participants even before conception and measured their hormones daily for six months (Jukic et al., 2013).

This means that the researchers knew the exact days that the participants ovulated, conceived, and even when their pregnancies implanted!

So what was the average length of a pregnancy in this study?

After excluding women who had preterm births or pregnancy-related medical conditions, the final sample of 113 women had a median time from ovulation to birth of 268 days (38 weeks, 2 days after ovulation).

The median time from the first day of the last menstrual period to birth was 285 days (or 40 weeks, 5 days after the last menstrual period).

The length of pregnancy ranged from 36 weeks and 6 days to one person who gave birth 45 weeks and 6 days after the last menstrual period. The 45 weeks and 6 days sounds really long... but this particular person actually gave birth 40 weeks and 4 days after ovulation. Her ovulation did not fit the normal pattern, so we know her LMP due date was not accurate.

The researchers also found that:

10% gave birth by 38 weeks and 5 days after the LMP

25% gave birth by 39 weeks and 5 days after the LMP

50% gave birth by 40 weeks and 5 days after the LMP

75% gave birth by 41 weeks and 2 days after the LMP

90% gave birth by 44 weeks and zero days after the LMP

Remember though, some of the participants did not ovulate on the 14 th day of their period (that's why you saw the statistic that 10% still haven't given birth by 44 weeks after the LMP!) So if we look at when people give birth after ovulation, you'll see this pattern:

10% gave birth by 36 weeks and 4 days after ovulation

25% gave birth by 37 weeks and 3 days after ovulation

50% gave birth by 38 weeks and 2 days after ovulation

75% gave birth by 39 weeks and 2 days after ovulation

90% gave birth by 40 weeks and zero days after ovulation

Women who had embryos that took longer to implant were more likely to have longer pregnancies. Also, women who had a specific sort of hormonal reaction right after getting pregnant (a late rise in progesterone) had a pregnancy that was 12 days shorter, on average.

So is the traditional "due date" really your due date?

Based on the best evidence, there is no such thing as an exact "due date," and the estimated due date of 40 weeks is not accurate. Instead, it would be more appropriate to say that there is a normal range of time in which most people give birth. About half of all pregnant people will go into labor on their own by 40 weeks and 5 days (for first-time mothers) or 40 weeks and 3 days (for mothers who have given birth before). The other half will not.

Are there some things that can make your pregnancy longer?

By far, the most important predictor of a longer pregnancy is a family history of long pregnancies- including your own personal history, your mother and sisters' history, and your baby's biological father's family history (Jukic et al., 2013; Oberg et al., 2013; Mogren et al., 1999; Olesen, et al., 1999; Olesen et al., 2003).

In 2013, Oberg et al. published a large study that looked at more than 475,000 Swedish births, most of which were dated with an ultrasound before 20 weeks. They found that genetics has an incredibly strong influence on your chance of having a birth after 42 weeks:

If you've had a post-term birth before, you have 4.4 times the chance of having another post-term birth with the same partner

If you've had a post-term birth before, and then you switch partners, you have 3.4 times the chance of having another post-term birth with your new partner

If your sister had a post-term birth, you have 1.8 times the chance of having a post-term birth

Overall, researchers found that half of your chance for having a post-term birth comes from genetics. This includes the baby's genetic tendency to gestate longer (due to genes the baby inherited from the mother and the father), and the mother's genetic tendency to carry a pregnancy longer. The Swedish researchers even proposed that you could call some pregnancies "resistant," because these mothers and/or fetuses have a genetically decreased tendency to start labor.

Other factors that may make your pregnancy more likely to go longer include:

Higher body mass index before you get pregnant (Halloran et al., 2012; Jukic et al., 2013; Oberg et al., 2013)

Higher weight gain during pregnancy (Halloran et al., 2012)

Longer time between when you ovulated and when your pregnancy implanted (Jukic et al., 2013)

Older maternal age (Oberg et al., 2013; Jukic et al., 2013)

Heavier birth weight of the mother (Jukic et al., 2013)

Higher education level of the mother (Oberg et al., 2013)

Being pregnant for the first time (Oberg et al., 2013)

Being pregnant with a male baby (Divon et al., 2002; Oberg et al., 2013)

Your mother had a post-term birth (Mogren et al., 1999; Olesen et al., 1999; Olesen et al., 2003)

The baby is measuring small by ultrasound at 10-24 weeks (Johnsen et al., 2008)

Experiencing environmental stress towards the end of pregnancy (at 33-36 weeks) (Margerison-Zilko et al., 2015)

What are the risks of going past your due date?

The risks of some complications go up as you go past your due date, and there are at least three important studies that have shown us what the risks are.

1. In 2003, Caughey et al. looked at 135,560 people who gave birth at term in California between the years 1995 and 1999 (Caughey et al., 2003). The participants in this sample all gave birth at Kaiser Permanente hospitals in northern California. The overall use of interventions (Cesareans and inductions) in this sample was not listed.

2. In 2004, Caughey et al. looked at the records of 45,673 people who gave birth in a single hospital in California from 1992 to 2002 (Caughey & Musci, 2004). The participants in this study were mostly well-educated. As far as intervention rates go, 18% gave birth by Cesarean and 16% with the help of vacuum or forceps. The rate of inductions was not listed.

3. In 2007, Caughey et al. studied the medical records of 119,254 people who gave birth after 37 weeks at Kaiser Permanente between the years of 1995 and 1999. This was the same time period and same hospital as his 2003 study, but this time the researchers only looked at low-risk people who had health insurance. The overall Cesarean rate was 13.8%, and 9.3% gave birth with the help of vacuum or forceps. The authors also took whether or not people had inductions into account when they calculated the risks of going past your due date (Caughey et al., 2007).

Risks for mothers:

The risk of chorioamnionitis (infection of the membranes) was lowest at 37 weeks (0.16%) and increased every week after that to a high of 6.15% at ≥ 42 weeks (Caughey et al., 2003)

The risk of endomyometritis (infection of the uterus) was lowest at 38 weeks (0.64%) and increased every week after that to a high of 2.2% at ≥ 42 weeks (Caughey & Musci, 2004)

The risk of having a placenta abruption (placenta separates prematurely from the uterus) was lowest at 37 weeks (0.09%), and increased every week to a high of 0.44% at ≥ 42 weeks (Caughey et al., 2003)

The risk of preeclampsia was lowest at 37 weeks (0.4%) and highest at 40 weeks (1.5%), after which the risk did not change (Caughey et al., 2003)

The risk of postpartum hemorrhage was lowest at 37 weeks (1.1%) and increased almost every week to a high of 5% at 42 weeks (Caughey et al., 2007)

The risk of a primary Cesarean (in people who have never had a Cesarean before) increased from 14.2% at 39 weeks to a high of 25% at ≥42 weeks (Caughey & Musci, 2004)

The risk of having a primary Cesarean for a non-reassuring fetal heart rate was lowest at 37-39 weeks (13.3-14.5%) and reached a high of 27.5% at 42 weeks (Caughey et al., 2007)

The risk of receiving forceps or vacuum assistance increased from 14.1% at 38 weeks to a high of 18.5% at 41 weeks (Caughey & Musci, 2004)

The risk of having a 3rd or 4th degree tear was lowest at 37 weeks (3.4%) and increased every week to a high of 9.1% at 42 weeks. However, these numbers are much higher than are typically seen, and are partially related to the high use of vacuum and forceps in this study.

In their 2007 study, Caughey et al. reported that high use of induction, Cesareans, and vacuum/forceps for people with increasing gestational age may contribute to an increase in maternal risks. However, when the researchers used a statistical method to control for the use of interventions, the risks still increased with gestational age.

Risks for infants:

The risk of moderate or thick meconium increased every week starting at 38 weeks, and peaked at ≥42 weeks (3% at 37 weeks, 5% at 38 weeks, 8% at 39 weeks, 13% at 40 weeks, 17% at 41 weeks, and 18% at >42 weeks) (Caughey & Musci, 2004)

Neonatal intensive care unit (NICU) admission rates were lowest at 39 weeks (3.9%) and rose to 5% at 40 weeks and 7.2% at ≥42 weeks (Caughey & Musci, 2004)

The risk of the baby being large at birth (>9 lbs 15 oz or >4500 grams) rose starting at 38 weeks (0.5%), and doubled every week after that up until 42 weeks (6%) (Caughey & Musci, 2004)

The odds of having a low 5-minute Apgar score went up starting at 40 weeks and increased each week until ≥42 weeks (exact numbers not reported; Caughey & Musci, 2004)

Other risks for post-term pregnancy include having low fluid, and something called dysmaturity syndrome (growth restriction plus muscle wasting), which happens in about 10% of babies who go past 42 weeks. For more information about meconium, see this article by Midwife Thinking about meconium stained waters.

What about the risk of stillbirth?

In this section, we will talk about how the risk of stillbirth increases towards the end of pregnancy.

There are two very important things for you to understand when learning about stillbirth rates.

First, there is a difference between absolute risk and relative risk.

Absolute risk is the actual risk of something happening to you.

For example, if the absolute risk of having a stillbirth at 41 weeks was 1.7 out of 1,000, then that means that 1.7 mothers out of 1,000 (or 17 out of 10,000) will experience a stillbirth.

Relative risk is the risk of something happening to you in comparison to somebody else.

If someone said that the risk of having a stillbirth at 42 weeks compared to 41 weeks is 94% higher, then that sounds like a lot. But some people may consider the actual (or absolute) risk to still be low-1.7 per 1,000 versus 3.2 per 1,000.

Yes-3.2 is about 94% higher than 1.7, if you do the math! So, while it is a true statement to say "the risk of stillbirth increases by 94%," it can be a little misleading if you are not looking at the actual numbers behind it.

Please see our handout on Talking about Due Dates for Providers for tips on how providers can discuss the risk of stillbirth.

The second important thing that you need to understand is that there are different ways of measuring stillbirth rates. Depending on how the rate is calculated, you can end up with different rates.

How do you measure stillbirth rates?

Up until the 1980s, some researchers thought that the risk of stillbirth past 41-42 weeks was similar to the risk of stillbirth earlier in pregnancy. So, they did not think there was any increase in risk with going past your due date.

However, in 1987, a researcher named Dr. Yudkin published a paper introducing a new way to measure stillbirth rates. Dr. Yudkin said that earlier researchers used the wrong math when they calculated stillbirth rates-they used the wrong denominator! (Yudkin, Wood et al., 1987).

Here's why this formula is wrong: We don't need to know how many stillbirths happen out of every 1,000 births at 41 weeks. Instead, we need to know how many stillbirths happen at 41 weeks compared to all pregnancies and births at 41 weeks. In other words, you have to include the healthy, living babies that have not been born yet in your denominator.

When researchers began using this new formula to figure out stillbirth rates, they found something very surprising-the risk of stillbirth decreased throughout pregnancy, until it reached a low point at 37-38 weeks, after which the risk started to rise again.

This finding-that the risk of stillbirth decreases throughout pregnancy, and then increases sometime after 37-38 weeks-has been found many times by different researchers in different countries. This phenomenon is called the "U-shaped curve" of stillbirth. In other words, there are higher rates of stillbirth earlier in pregnancy, then they go down until around 37-38 weeks, after which they rise again.

Because the risk of stillbirth starts to go up even more at 40, 41, and 42 weeks, some researchers argue that although 40 weeks and 3-5 days may be the physiological length of pregnancy, 40 weeks may be the functional length of a pregnancy.

In other words, the average pregnancy normally lasts about 40 weeks and 5 days, but in some researchers' opinion, because of the increased risk of stillbirth and newborn death, 40 weeks may be as long as a pregnancy should go.

And although the stillbirth rates may seem low overall, if you happen to be a parent who experiences the 1 in 315 event at 42 weeks (Muglu et al. 2019), then the risk doesn't seem so low anymore.

Actual stillbirth rates vs. open-ended stillbirth rates

Even after researchers began using the new way of calculating stillbirth rates, there was still controversy about the best way to calculate this new formula for measuring stillbirth rates.

Different than what Yudkin proposed in 1987, some researchers preferred an "open-ended" stillbirth rate (also known as the "prospective risk of stillbirth"). An open-ended stillbirth rate at 40 weeks would tell us what a pregnant person's risk of stillbirth was for any time after 40 weeks, if she let the pregnancy continue indefinitely.

Other researchers argued that most people (and doctors!) don't want to know what the risk of stillbirth would be if a pregnant person chose to let the pregnancy continue on and on! (Hilder et al., 2000). They just want to know what the risk would be if they waited one more week until the next appointment, or even a few days.

But the "open-ended" stillbirth rate tells you what your risk of stillbirth at 40 weeks would be if you include babies born not just at 40 weeks, but 41 weeks, 42 weeks, 43 weeks, and on! (Boulvain et al., 2000).

In the end, you will find that stillbirth rates vary from study to study, depending on whether the researchers report the actual stillbirth rate, or the open-ended stillbirth rate.

So what is the risk of stillbirth as you go past your due date?

Since the late 1980's, there have been at least 12 large studies that looked at the risk of stillbirth during each week of pregnancy. Some of the researchers used open-ended stillbirth rates, and some of them used actual stillbirth rates.

All of the researchers found a relative increase in the risk of stillbirth as pregnancy advanced.

To get an accurate picture of stillbirth in people who go past their due date, it would be best to look at studies that took place in more recent times. I've chosen 3 of the most recent studies to show you from Norway, Germany, and the U.S. To see all of the other studies, click to view the entire table here.

All 3 of these studies used the actual stillbirth rate-not the open-ended stillbirth rate. Two studies used ultrasound to calculate gestational age, and one study used the LMP.

The largest meta-analysis to date on risks of stillbirth and newborn death at each week of term pregnancies was published in 2019 (Muglu et al. 2019). A meta-analysis is when researchers take multiple studies and combine all the data together into one big "meta" study. The researchers included 13 studies (15 million pregnancies, nearly 18,000 stillbirths). All of the studies were conducted in countries defined as "high-income" by the World Bank.

The risk of stillbirth per 1,000 was 0.11, 0.16, 0.42, 0.69, 1.66, and 3.18 at 37, 38, 39, 40, 41, and 42 weeks of pregnancy, respectively. Based on their data, Muglu et al. (2019) calculated the "number needed to harm" by waiting for labor for one more week in order to experience one additional stillbirth. To experience one additional stillbirth, there would need to be at least 2,367 people waiting for labor for one more week starting at 39 weeks. At 40 weeks, 1,449 people would have to wait for labor for one more week to experience one additional stillbirth. At 41 and 42 weeks, only 604 and 315 people, respectively, would have to wait for labor for one more week to experience one additional stillbirth.

The researchers also found evidence that health care systems are failing Black mothers and babies-an alarming but common theme in health care research. Black mothers were 1.5 to 2 times more likely than White mothers to have a stillbirth at every week of pregnancy.

When they looked only at low-risk pregnancies, the risk of stillbirth was 0.12, 0.14, 0.33, 0.80, and 0.88 at 38, 39, 40, 41, and 42 weeks of pregnancy. Low-risk pregnancy was defined as pregnancies with a single baby, no congenital abnormalities, and no medical conditions in the mother.

There was no additional risk of newborn death when giving birth between 38 and 41 weeks, but the risk of newborn death did increase beyond 41 weeks.

So, although most researchers have found an increase in stillbirth rates in the late term and post term period, some might consider the "absolute" increase in risk to be small until 41 weeks, after which it reaches about 0.80-1.66 out of 1,000, depending on the mother's risk factors for stillbirth.

What factors can increase the risk of stillbirth?

Researchers have found several factors are related to a higher risk of stillbirth:

Post-term babies who are small for gestational age (body weight <10 th percentile) have a 6-7 times higher chance of stillbirth and newborn death than post-term babies who are not small for gestational age.

Also, small for gestational age babies are often growth restricted at the 18-week ultrasound. So, the gestational age for these babies is often under-estimated.

This means that babies who are small for gestational age may be more post-term than we realize they are-increasing their risk while also leaving us unaware of their true gestational age (Morken et al., 2014).

Other factors that do not necessarily cause stillbirth but may increase the risk of stillbirth, in general, include:

Belonging to an ethnic group at increased risk for stillbirth* (Ananth et al., 2009; Stillbirth Collaborative, 2011)

Being pregnant with your first baby (Huang et al., 2000; Smith, 2001b; Stillbirth Collaborative, 2011; Flenady et al., 2011)

Fewer than four prenatal visits or no prenatal care (Huang et al., 2000; Flenady et al., 2011)

Low socioeconomic status (Huang et al., 2000; Flenady et al., 2011)

A body mass index (BMI) over 25 to 30 (Huang et al., 2000; Stillbirth Collaborative, 2011; Flenady et al., 2011)

Smoking (Morken et al., 2014; Flenady et al., 2011)

Pre-existing diabetes (Stillbirth Collaborative, 2011; Flenady et al., 2011)

Pre-existing hypertension (Flenady et al., 2011)

Older maternal age (≥40 years) (Stillbirth Collaborative, 2011)

Not living with a partner (Stillbirth Collaborative, 2011)

History of previous stillbirth (Stillbirth Collaborative, 2011)

Being pregnant with multiples (Stillbirth Collaborative, 2011)

* Racism, including the effects of prejudice and institutional racism, can increase the risk of poor outcomes, including stillbirth, in certain populations (Giscombe and Lobel, 2005).

Of course, parents can still experience the stillbirth of a child even when none of these risk factors are present. As many as a third of all stillbirths that take place before labor have no known cause (Warland & Mitchell, 2014). To read more about theories of unexplained stillbirth, read this article here.

We have heard some clinicians state that the "aging of the placenta" is a potential cause of stillbirths with no official known cause. However, up until recently, there was no research on this topic.

In 2017, researchers published the first study looking at biological markers of aging in placentas. In this study, researchers in Australia collected placentas from 34 people who gave birth between 37-39 weeks of pregnancy, 28 people who gave birth between 41-42 weeks, and 4 people who experienced stillbirths between 32 and 41 weeks (Maiti et al. 2017).

Five or more tissue samples were removed from each placenta, and the samples were analyzed using a variety of biochemical tests. For example, one of the tests looked for a marker of DNA/RNA damage that was previously observed in other aging tissues, such as the brain in Alzheimer's disease. There was a significant increase in DNA/RNA damage in late-term and stillbirth placentas compared to the placentas from 37-39 weeks.

Overall, the analysis of the placentas from the 41-42 week pregnancies and from the stillbirths showed increased signs of aging, with decreased ability to transport nutrients to the baby and waste products away from the baby, compared to the placentas from the earlier term births. The rate of placental aging varied in different pregnancies, and the authors stated that not all of the 41-42 week placentas showed signs of aging. We reached out to the authors to find out more, and they told us that one-third of the 41-42 week placentas showed increased signs of aging compared to the 37-39 week placentas. This means that two-thirds of the 41-42 week placentas did not show signs of aging.

Interestingly, the authors say that in the future it may be possible to predict which babies are at increased risk of stillbirth by measuring markers of placental aging in the mother's blood. You can watch a 10-minute video describing the findings of this emerging research here.

Induction for Going Past Your Due Date

Check out our Signature Article on Inducing for Due Dates here for more information about the Pros/Cons of induction versus waiting for labor.

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What is an estimated due date, and how is it determined? What are the risks of going past your due date? Does induction increase the risk of Cesarean? At which point do the benefits of being electively induced outweigh the risks? Does a person's goals and preferences for their births

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Most women in the UK get their maternity care for free through the NHS, but there are also private options available.
From paying for scans and doulas to private hospitals and amenity beds, this guide explains what services are available before, during and after giving birth.

We also list the pros and cons for both NHS and private maternity services and reveal what you might expect to pay if you decide to go private.
For ways to keep your family living costs down, and kids of all ages happy,
NHS vs private maternity care: pros and cons

Whether you choose private or NHS maternity care, there are benefits and disadvantages. We'll go into more detail further down the page but here's a quick overview of how they differ.

NHS maternity care: pros

It's free. This is from your first appointment through to scans, antenatal care, the birth itself and postnatal care. There may be some exceptions for non-UK residents but you'll never be turned away from NHS maternity care.

Access to a range of experts. If your birth becomes complicated, you'll have direct access to some of the world's best experts, without having to worry that your costs will rack up.

You still have choices. Whether it's at home, in a hospital or at a birth centre, having an NHS birth still gives you scope to somewhat tailor your experience. You have more options than you might realise. For example you can ask to use a different hospital rather than one that your GP may refer you to locally and you can also request to have an elective c-section .

NHS maternity care: cons

You might not get the birth you want. For example, if you've chosen a water birth but all the birthing pools at your chosen facility are occupied when you need one. The NHS will try to support your wishes but it may not always be possible.

You might not feel as supported as with private care. Staff shortages are a reality in NHS hospitals compared to private hospitals. Also, shift changes can mean you might have various midwives looking after you, even when you're labouring and this may be unsettling for you at the various stages of your pregnancy and birth.

Private maternity care: pros

A team of familiar experts. Whether it's an obstetrician or midwife-led delivery, you'll have the added reassurance of getting to know your team throughout your maternity care and birth.

Regular contact. One of the things you're paying for is their time so you may feel you can contact the facility as much as you like without feeling like you're bothering anyone. You might even have the mobile number of your obstetrician for out of hours use.

Hotel-like facilities. Luxury and privacy are standard and facilities often include 24-hour room service, satellite TV and premium toiletries in your ensuite bathroom. Unlike NHS hospitals, which tend to be strict on visiting hours, there may be more flexibility for visitors to come and see you if you've gone private, plus your partner may be able to stay.

Private maternity care: cons

It's expensive. Private care can cost many thousands of pounds and even with a package there may be lots of added extras such as epidurals, induction or instrumental delivery. The earlier in your pregnancy you start with a care package, the more you'll pay. You'll also pay more if you're expecting multiples.

You may end up with NHS treatment anyway if something goes wrong. The Portland Hospital for example has its intensive care facilities for newborns and mums, but most private delivery services are situated within or next to NHS hospitals and will use their facilities in an emergency, such as the obstetric emergency theatre on a standard labour ward.

There might not be one near you. Private maternity facilities aren't as common as NHS ones so you may have to travel to get to one. If your birth happens quickly and unexpectedly, you might not have time to get there. Most are in the London area so if you factor in antenatal care and unforeseen events such as going into labour early, it might not work for you unless you're London-based.

- our guide makes sure you have everything you need
Can I give birth in a private hospital?

Yes, you can choose to give birth in a private maternity hospital or unit or pick and choose aspects of private maternity care that suit your needs.

For example, although the NHS offers expectant mums at least two ultrasound scans during pregnancy , some people want 3D or 4D scans to see the baby's features more closely and these are only available privately.

What's it like giving birth in a private hospital?

If you're giving birth in a private hospital or on a private wing, your obstetrician will usually look after you in labour, but you can also have midwife-led care, depending on the package you've paid for.

Once you've given birth, you'll have a private ensuite room at the hospital with hotel-like facilities such as a concierge, luxury toiletries and 24-hour room service.

The cost of your room is usually included in the price although you can pay more to stay for extra nights or to upgrade to a suite.

Private midwives will then support you for your immediate postnatal care.
Taking baby home in a car? Make sure you choose one of our
How much does it cost to give birth at a private hospital?

When we looked in December 2022, the lowest cost we found for a vaginal/normal delivery with a consultant at a private hospital was £5,500 and the lowest for a c-section was £6,300 but this is a starting price. There are a number of variables and added extras to factor in when working out what the total cost might be.

Consultant-led or midwife-led delivery? A 'consultant-led' normal birth is different from a 'midwifery-led' birth, which is generally suitable for low-risk pregnancies. However, it still isn't cheap - we found one that started at £8,015 but extra charges could be added on if you stay beyond one night and have interventions such as an epidural or induction.

Your consultant's professional fees will be charged separately and it's likely the anesthetist's will too, so contact their administrative staff beforehand for an idea of what these might be.

Vaginal delivery, elective c-section or emergency c-section? Each of these incur a different cost. For example, a consultant-led 'normal' delivery at the Lindo Wing of St Mary's Hospital in Paddington has a basic price of £6,300 whereas a consultant-led c-section is £8,000 (plus consultant's fees in both cases). Not only that but you may want to check how many nights' stay you get after a c-section. Some, such as the Westminster Wing at Guy's and St Thomas' Hospital , include two nights' stay whereas many others only include one then charge anything from £750 to £1,325 for each additional night.

Unexpected extras. Unforeseen interventions such as epidurals, instrumental deliveries, inductions and delivering a baby in breech position may be charged for separately and could collectively add thousands to your final bill, not to mention if you end up having an emergency c-section. You may need to spend some time in hospital before the birth and you'll be charged for this, too. For example, per night an antenatal admission at the Kensington Wing at Chelsea and Westminster Hospital costs £1,325.

Where you live. It may be that where you live could affect not only your access to private maternity facilities, most of which are based in London, but also what you pay. Although a London private birth is expensive, one offers private delivery including up to a three-night hospital stay (plus follow up) for £17,000.

How do you pay? You may be asked to pay half of your fees as early as 20 weeks and although some private facilities offer payment plans, many will ask for BACS transfer or credit card payment. Get a breakdown of what's included before you sign up.

Why do parents choose to give birth in a private hospital?

In our 2022* survey, we asked 1,424 parents about where they had given birth - almost all had done so in an NHS hospital (90%) and around 4% gave birth in a private hospital or private wing.

There are various reasons you might choose to give birth in a private hospital or clinic, including:

A desire for additional comfort and/or privacy

Having more say in your care

The chance to develop a closer relationship with your midwife and/or consultant

Easy access to additional scans such as 3D and 4D ultrasound scans

*Baby & Child survey carried out in February 2022. - we compare the leading brands to discover whether one is better than another
What maternity care can I get on the NHS?

NHS antenatal care

With the NHS, you get seven to 10 antenatal appointments with a midwife, as well as blood tests and at least two free .

If you have more complicated needs, you'll also see a consultant (doctor) in addition to your midwife appointments.

NHS when giving birth

Most women have their baby in an NHS maternity unit. If you choose to have a home birth, two NHS midwives will come to your home to support you during the birth.

Whether you give birth in a birth centre or a labour ward, you'll always have your own room for the birth itself and be looked after by midwives. However, if you're induced you may need to spend time on a shared antenatal ward.

Similarly, if you need to stay overnight after the birth it's likely you'll be moved to a postnatal ward, where you'll be sharing a room and bathroom with a number of other women and their babies.

NHS postnatal care

Immediately after giving birth in an NHS facility, you'll go home a few hours after a straightforward birth or after a couple of days if you've had a c-section or experienced complications.

You'll have postnatal appointments with NHS midwives once you're back home. This may be at your home, or at a local clinic or children's centre.

The number of appointments varies, but most women tend to see a midwife three or four times postnatally.
We reveal the and offer useful buying advice
How can I enhance my NHS maternity care?

You can still choose aspects of private maternity care to suit your needs, even if you're not going completely private. In fact, our 2022 survey showed that out of just over 1,400 parents, nearly all had paid for private services during pregnancy or birth.

Private pregnancy scans and blood tests

Our 2022 research showed that almost all parents (83%) had a private scan during the pregnancy and around one in five (19%) had a private blood test.

The NHS provides you with all the diagnostic scans you need but some people pay for extras such as 3D and 4D scans at private clinics or private hospitals to enhance their experience, such as being able to see their baby's features more clearly and to get video footage of it.

For more information see our guide to NHS and private ultrasound scans during pregnancy .

Private amenity room after the birth

Women having an NHS birth sometimes choose to pay to hire a private 'amenity' room within the NHS maternity unit, which give you more privacy but where you'll still be looked after by NHS midwives.

The rooms are often just off the postnatal ward, and can cost anything from around £80 up to five times that, depending on where you are in the UK.

Our research showed that while just 6% of parents opted for a private amenity room in the NHS, almost all (97%) found it useful.

Hiring a doula

A doula is someone who has training in supporting expectant and new parents, rather than a health professional, and as such they're not there to replace midwives or other health staff.

Your doula can work with you during your pregnancy, be with you as a birth partner or advocate, or provide support in the early days postnatally - their service is tailored to your needs.
See all our
In our survey, 5% of respondents paid to have a doula and 90% said they found it useful.

Is NHS maternity care always free?

The rules say no-one should ever be denied NHS maternity care, but in some cases it isn't free.

The UK has a residence-based healthcare system so if you are 'ordinarily resident' here you're entitled to free NHS maternity care, whatever your citizenship or immigration status.

However, who is considered 'ordinarily resident' when it comes to NHS charging is complicated and the charity Maternity Action has a guide to who is considered 'ordinarily resident' in the UK to help you see where you stand.

Each NHS Trust has an Overseas Visitor Team with responsibility for reaching a decision about whether you'll be charge for your maternity care if you aren't ordinarily resident.

Can I choose to go private mid-way through my pregnancy?

Yes, and this may give you the benefit of some private care but without incurring the full cost.

To give you some idea, delivery by an obstetrician at the private facility of is £6,500 from 12 weeks of pregnancy, £5,500 from 28 weeks, £5,000 from 32 weeks and £4,500 from 36 weeks, although you'll generally pay 50% of your fees as early as 20 weeks and the remainder by 36 weeks.

Some private facilities - for example, the Sir Stanley Clayton Ward at Queen Charlotte's and Chelsea Hospital in west London - have a consultant-led late transfer elective c-section package suitable for patients from 38 weeks onwards and this starts at £6,795 (excluding extras).

However, in other situations you could find that the amount it costs is the same as if you started it early on in your pregnancy.

For example, , which represents independent midwifery, says that because an independent midwife has fixed costs to bear and will often have to work harder within a short space of time to give you the care you need, you still pay the full amount.

If you cancel - for example, to return to the NHS - you may be charged a cancellation fee (e.g. £400 at the Lindo Wing).
- our pick of the top products to make feeding your baby easier
You should be aware that, as per Department of Health guidelines, if you transfer from private to NHS care you're not permitted to change back to private care.

Can I pay for a private room in an NHS hospital after the birth?

The availability of private or 'amenity' rooms following delivery varies from one hospital to the next, as does the price.

Some offer single amenity rooms with shared facilities and some have private rooms with ensuite facilities. They may also have tea and coffee facilities and a television - some even allow someone to stay with you overnight.

However, even if your hospital has them, there's no guarantee you'll get one. They tend to be allocated on a first-come, first-served basis and can't be held or booked in advance.

Also, if you are occupying an amenity room that is needed by someone with a clinical need, you may have to relocate to an alternative room or a postnatal ward.

The cost varies from one hospital to the next but can start at around £80 for a single room with shared bathroom facilities, rising to, in some cases, upwards of £400 a night but whatever you pay, you are still an NHS patient and won't be given preferential treatment.

Can I hire a private midwife?

Yes, if you want more flexibility in your maternity care than the NHS can provide, you can look into hiring a private or independent midwife.

says a complete package of care throughout pregnancy, birth and the postnatal period costs anywhere between £2,000 and £5,000, although it can cost as much as almost £9,000.

Most independent midwives are happy to accept payment in instalments or flexible payment plans, and in some special circumstances they may consider caring for women for a reduced fee.

In this video, an independent midwife explains what she believes are the benefits of using a paid-for, non-NHS midwife for maternity care.

Having a home birth with a private midwife

Many women who choose to have an independent or private midwife are planning to have a home birth.

Private midwives can be a good option if you're finding it difficult to get support for a home birth from your local NHS services.

If you're having a home birth with a private midwife, there's still the possibility you may need to be transferred to hospital because you or your baby needs extra help.

In this case, the NHS midwives and doctors in the hospital will take over your care. However, your private midwife will still be there to act as a supportive birth partner.

Postnatal care with a private midwife

Women who have given birth with private midwives can pay to carry on seeing the same midwife they had throughout their pregnancy, after the baby is born.

Others may choose to supplement their NHS postnatal care by having additional private appointments as well.
See all our for information on child car seats, pushchairs, baby monitors, nursery furniture and much more.
As well as providing continuity of care, a private midwife can assist if you're having problems with breastfeeding and will also be a familiar face if you've had a challenging or difficult birth.

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NHS vs private maternity care: what are your options? - Which?

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We compare the pros and cons of NHS and private maternity care. Learn about the antenatal care and birth options available for free through the NHS, and what private midwives and hospitals can offer, how much it costs and what you can access

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Cephalic version by moxibustion for breech presentation

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There is some evidence to suggest that moxibustion may be useful for turning babies from breech presentation (bottom first) to cephalic presentation (head first) for labour when used with either acupuncture or postural techniques of knee to chest or lifting buttocks while lying on the side.

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#covidmaternity

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Information on coronavirus for pregnant BAME women

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Hit play above to watch Dr Christine Ekechi give information on coronavirus for pregnant women from a Black, Asian or other ethnic minority background.

Learn more: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/

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(updated 17th March 2022)

If you are pregnant, you may be concerned about how coronavirus or COVID-19 (the illness resulting from coronavirus) will affect your rights to maternity care. The NHS has general information on its website about coronavirus (separate guidance applies to Scotland, Wales and Northern Ireland). In addition NHS England & Improvement has specific guidance for providers about facilitating visiting in maternity services. The Royal College of Obstetrics and Gynaecology (RCOG) has information for pregnant women and their families on its website, which will continue to be updated. The relevant Royal Colleges (the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives and the Royal College of Paediatrics and Child Health) have also published this information for maternity healthcare professionals.

You can read our March 2020 position statement here.

Click below to view our template letters to Trusts/ local MPs re visiting restrictions:
Template letter to local Trust about visiting restrictions due to COVID
Template letter to your local MP about visiting restrictions due to COVID
Frequently Asked Questions

What rights do I have as a pregnant woman in the pandemic?

You still have the right to a safe and positive birth experience. This includes being treated with dignity and respect, having a companion of choice, having access to pain relief, being able to be mobile in labour and give birth in the position of your choice, and being communicated to clearly by staff. On the postnatal ward, your essential needs for food, drink and physical support must be met.

Will I still receive maternity care as normal?

You will still receive maternity care. However in some cases your care might be slightly different to what you expected. The latest guidance from the Royal Colleges recommends that the normal schedule of antenatal appointments should be provided if at all possible. However, depending on local circumstances some appointments may be conducted over the phone or by video link. If you have, or may have, COVID-19, then routine appointments, including scans, should be delayed until after your isolation period.

Will I have to accept changes I am not happy with?

Maternity services should still treat you with dignity, and you can always decline any intervention/treatment you are not happy with. However in some cases Trusts/Boards may have to make changes to the services they offer. The law allows them to do this, even if it means restricting choices, if they can show that it is a proportionate response to the challenge of coronavirus.

I have been planning a home birth, will I still be able to have one?

Yes, if the Trust/Board has enough staff to run this service and women are able to be transferred to hospital if necessary.

Official guidance recommends that women who have (or may have) COVID-19 give birth on an obstetric unit. If the Trust/Board is not able to offer a home birth to well women, they should be able to give a good, evidence-based reason for this, and to offer alternatives such as birth in a midwifery-led birth centre, where possible. They should also review this decision regularly as the situation changes, for example, if the home service has been partially withdrawn because of staff shortages of over 20%, the expectation is that the service should be reinstated once staff shortages return below 20%. RCM/RCOG have also published guidance on the provision of midwifery settings and home birth during the current pandemic.

If there is no home birth service what happens if I stay at home and give birth without assistance?

The legal position is that you cannot be compelled to go to hospital and giving birth without assistance is not illegal, but should be thought about carefully.
Some women have reported being threatened with social services when mentioning this option. This is completely inappropriate. A referral to social services should only be made on the basis of a risk of "significant harm" to the baby after the baby is born, and should never be made on the basis of birth choices alone.

I am due to have a maternal request caesarean, will this still go ahead?

Yes, unless the Trust can give a good reason why the Trust cannot honour that commitment due to the changed circumstances. Caesareans will be prioritised according to clinical need but Trusts should be doing their best to follow NICE guidance, and to undertake all caesareans on their lists, even if some re-scheduling is required.

Will I still have continuity of care?

National guidance from the Royal Colleges says that continuity of care should continue to be offered where possible. Each Trust continue to monitor if it has sufficient staff to offer its usual service, and to make short-term alternative arrangements to see a midwife or doctor even if not your usual one.

Will I have one to one care in labour?

Yes - all units aim to provide you with one to one care from a midwife during active labour.

Will my partner be able to be with me at all times?

You should always have a chosen partner with you during active labour and birth (ie from when you are admitted to the labour ward or birth centre and are therefore in your own room, or during a caesarean unless you are having a general anaesthetic).

Some Trusts continue to have restrictions on visiting in place particularly on postnatal wards (for example visiting limited to two hours). These can only be justified if there are issues with maintaining 1m social distancing if all partners were present. A Trust must be able to show that ongoing restrictions are necessary and proportionate, taking into account the need to control the spread of the virus as well as the harm caused by the restrictions themselves. Trusts are required to be innovative in overcoming any obstacles in the way of including partners within maternity services.

Visiting should only be restricted on the postnatal ward if the staff are able to meet all your basic needs for food, drink and physical support. If you need additional support, for example if you have had a caesarean, or you have had twins, or you have a mental health condition, exceptions should be considered on a case by case basis.

If visiting restrictions are still in place and you feel that there are reasons to make an exception for you, do raise this with your care team.

Please note the situation regarding visiting in maternity services differs across the UK. You can find further information here on current visiting guidance in England, Scotland, Wales and Northern Ireland.

Can my partner join appointments by phone or video call if they are not able to be present in person?

Partners are now able to attend most antenatal and scan appointments. Where this is not possible, many Trusts are facilitating partners dialing into appointments with midwives and doctors. If you are prevented from doing this, you should be given a good, evidence-based reason. Healthcare professionals should bear in mind that the General Medical Council and the British Medical Association have said that patients should be able to record consultations.

We have received legal advice saying that Trusts/Boards should allow partners to be involved in scan appointments remotely unless the Trust/Board can show they have looked at all the evidence and have a good reason to say no. Updated national guidance on remote attendance was published by the Society of Radiographers on 12th August 2021 and provides some ideas about how discretion can be applied when partners are not able to attend in person.

Do I have the right to decide who is present at my home birth?

A Trust/Board cannot compel people to leave your house. However Trusts/Boards have a duty to keep their staff safe so they can restrict their service and say they won't attend in certain circumstances, say if someone with a positive COVID test or symptoms is present. By declining to provide the service, the Trust/Board is potentially putting the woman and baby at risk and may be legally liable in the event of an adverse outcome. Therefore Trusts/Boards will need to assure themselves that the restriction is proportionate. For example, requiring other members of the household including other children, to leave the house during the birth, is unlikely to be proportionate.

Will I have access to pain relief during my labour?

Yes. Trusts should not withhold pain relief including access to water to relief pain in labour, as well as access to an epidural or other drugs without having a rational and evidence based reason to do so.

Will I need to wear a face mask during a caesarean?

There is no official guidance on this but RCOG have told us the following:

"The NHS guidance on wearing face coverings in hospital settings applies to staff, visitors and those attending out-patient appointments, not people admitted to hospital. We do not believe it is appropriate for pregnant women in labour or those having a planned or emergency caesarean birth to be asked to wear a facemask while in labour or when giving birth."

"Pregnant women admitted to hospital who tested positive for or who are displaying symptoms of COVID-19, would usually be asked to wear a face covering until they are moved into a private room, or while moving from their room to the operating theatre if they are having a caesarean birth."

Do I have the right to decline testing for COVID?

Yes you can decline the test and care must not be withdrawn. RCOG's guidance on testing says that if you decline a test you should be treated as if your test result is pending (ie you should be treated as positive if you have symptoms or have been in close contact with someone who has symptoms or a positive result). RCOG's guidance can be found here.

Should I be prioritised for vaccination?

As of 16 th December 2021 pregnant women and birthing people have been prioritised for vaccination (alongside anyone under 65 who has a long term health condition). This follows evidence that clinical outcomes for pregnant women with COVID have worsened over the pandemic (see here for further information).

Vaccination sites have been given operational guidance telling them that they need to make reasonable adjustments for people who might struggle to stand in a queue including those who are pregnant.

What if I am under 18?

Anyone who is pregnant should be prioritised for the vaccine. If you are over the age of 12 you can have the Pfizer vaccine.

Do I have the right to decline vaccination?

Everyone has the right to make an informed choice over whether to be vaccinated or not. However the Joint Committee on Vaccinations and Immunisation is calling on all pregnant women to get vaccinated as soon as possible. There is now good available data which shows no safety concerns with vaccinating pregnant women. If you have any concerns we would recommend looking at the latest information and data from reputable sources such as the Royal College of Obstetrics and Gynaecology (see here).

Does all of this apply to Scotland, Wales and Northern Ireland?

The Human Rights Act applies to the whole of the UK and therefore the underlying principles of: individuals having rights which can't be restricted without good reason, the need to explore all alternative options to ensure restrictions are the minimum necessary to achieve the legitimate aim of protecting the health of others, and the need to review these decisions as the situation changes, apply equally to the devolved nations.

RCOG/RCM guidance also applies UK wide.

The situation regarding visiting in maternity services differs across the UK. You can find further information here on current visiting guidance in England, Scotland, Wales and Northern Ireland.

What about the rights of staff?

We understand that maternity staff are currently working in very challenging circumstances and are understandably worried about the risk of catching COVID and of passing it on to family members.

Midwives, doctors and other NHS staff have rights as employees, including the right to a safe workplace, and to protective equipment. However NHS Trusts as public bodies also have a duty to protect the human rights of the patients they look after. Trusts must balance the need to protect their staff against the need to protect the rights of their patients. Whilst banning all birth partners, for example, could reduce the risk of infection to staff, it would be a profound restriction on the rights of a woman and her partner. Such a ban would only be proportionate in the most extreme circumstances.

We recognise the dedication and sacrifice of maternity healthcare professionals who are facing increased risks on a daily basis to ensure that women have a safe and positive birth experience.

If you feel your rights during birth are at risk, please do email us on advice@birthrights.org.uk

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Coronavirus - how will it affect my rights to maternity care? - Birthrights

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(updated 17th March 2022) If you are pregnant, you may be concerned about how coronavirus or COVID-19 (the illness resulting from coronavirus) will affect your rights to maternity care. The NHS has general information on its website about coronavirus (separate guidance applies to Scotland, Wales and Northern Ireland).

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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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RCM guidelines for midwives

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by the Royal College of Midwives

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Throughout the pandemic, our visiting policy has been developed in line with Public Health England and NHS England national guidance and in response to changing infection rates in London to protect patients, their visitors and staff.
You can bring one support partner to: Outpatients:

All scans

All midwife appointments

All Fetal Medicine Unit appointments

All attendances to the Maternal Fetal Assessment Unit

Please note that this does not include GTT glucose tests.

Visitors for outpatient appointments will be required to wait just outside the building as waiting areas inside the hospital cannot accommodate all patients and visitors while socially distanced. Visitors will be able to join patients when they are brought into a room and the appointment starts.

Inpatients:
2 x support partners for:

Admissions for induction of labour

Admissions for labour and birth

We are pleased to update you with the changes to our Maternity Visiting as below:

Birthing partner can stay for 24 hours on Birth Centre, Postnatal Ward & ACU.

Second person can visit the Birth Centre, Postnatal Ward & ACU (including children/siblings) between 2-8pm

Please note this only applies to Maternity Inpatients (Birth Centre, Postnatal Ward & ACU) for the time being.

Our Neonatal Unit visiting is currently under review.

All visitors for all outpatient and inpatient appointments will require an ID badge which is produced on that day for that day only by ground floor reception staff.

We recommend that visitors arrive 15 minutes before the scheduled appointment time to allow time for this badge to be produced.

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Maternity services : University College London Hospitals NHS Foundation Trust

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Throughout the pandemic, our visiting policy has been developed in line with Public Health England and NHS England national guidance and in response to changing infection rates in London to protect patients, their visitors and staff.

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Guidance from Queen Charlotte's/St Mary's

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Guidance from Queen Charlotte's/St Mary's

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As we continue to move out of the Covid-19 pandemic, we have removed many of our remaining Covid-19 measures in line with national NHS guidance.

We've learned a lot over the past two years which is helping us understand how best to keep everyone safe as we return to more usual ways of working. We are now focusing more on best practice prevention and control measures for key infections, not just Covid-19.

Currently:

you are not required to wear a face mask or physically distance in non-clinical areas, including entrances, lifts, stairwells and restaurants

we have removed the requirement to wear masks in some clinical areas - depending on the risks of infection for patients and staff. You will not be required to wear a mask in most outpatient, maternity or diagnostic clinic waiting areas

you are required to wear a mask in inpatient areas and clinical treatment rooms (including outpatient and diagnostic treatment rooms)

our staff - supported by local signage - will let you know if you are in an area where you still need to wear a mask

visiting has returned to our pre-pandemic approach. You do not need to book a visiting time but, as before, you will need to check visiting hours for the specific ward or unit. If you are visiting someone who has an infection - or who is especially vulnerable to infection - you will be required to wear a face mask and, in some cases, other personal protective equipment. Staff locally will let you know what is required. Find out more about visiting

if you are coming in for an outpatient, maternity or diagnostic appointment, you are welcome to have someone with you. However, for A&E, please attend alone wherever possible - space remains very limited and there is always more risk of infection in A&E departments. We will keep our approach for A&E under review.

In addition, there are many measures in place that you will not see that help to keep everyone safe:

our staff undertake regular lateral flow tests for Covid-19 and stay away from work if they test positive

patients attending for procedures must take a lateral flow test at home within 24 hours of their appointment and complete a Covid-19 checklist

we have separate care areas for patients who have - or may have - Covid-19 or other respiratory infections

As always, for anyone coming in to our hospitals:

do not come if you have any symptoms of respiratory illnesses such as flu or Covid-19 (unless emergency attention is needed)

use hand sanitiser or wash your hands as you enter the hospital and when entering or leaving any department

follow any local infection prevention and control measures, as advised by staff and signage

you are always welcome to wear a mask if you wish to do so, even where it is no longer a requirement.

What if I'm exempt from wearing a face mask?

If you are asked to wear a face mask in a particular area but are exempt from doing so, speak to our clinical staff. They will find suitable, alternative ways for you to wait, be treated or visit in order to manage the additional risks to you and those around you.

Covid-19 vaccination

We continue to urge everyone who is eligible to be vaccinated against Covid-19.

Read more about Covid-19 vaccinations and how to book one.

Planned care

All patients must do a lateral flow test at home within 24 hours of their appointment and complete the Covid-19 checklist. This includes patients who:

need to do a PCR test 3 days before their procedure or surgery date, as advised by their care team

are fully vaccinated

During the height of the pandemic, as we had to focus more on caring for patients with Covid-19 and other urgent and emergency needs, our waiting lists for planned care grew. It is the same across the whole NHS. Our clinicians prioritise all patients waiting for care according to individual clinical need. Waiting times will be different for different people, even those with the same condition. If you require care more urgently, you will be seen more quickly. We are increasing our planned care capacity and have a number of other initiatives in place to help reduce our waiting times as quickly as possible.

If you or a family member are waiting for hospital treatment, you can access the NHS My Planned Care digital platform which provides the latest average waiting times across all NHS trusts.

The My Planned Care platform also provides helpful advice and support while you are waiting, including details on how to manage any pain, your mental health, keeping healthy and accessing financial help and other local support. It can also help you to prepare for your care, including how to make a plan for your care and treatment alongside your healthcare professional.

Find out more about preparing to come into hospital for a planned procedure or surgery.

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As we continue to move out of the Covid-19 pandemic, we have removed many of our remaining Covid-19 measures in line with national NHS guidance. We've learned a lot over the past two years which is helping us understand how best to keep everyone safe as we return to more usual ways of working.

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NHS Guidance: Pregnancy and your risk from COVID-19
COVID-19 (coronavirus) information for maternity patients planning to give birth at the Royal Free London NHS Foundation Trust London

We would like to take this opportunity to update you about your maternity care at the Royal Free London during the COVID-19 (coronavirus) pandemic and reassure you that yours and your baby's safety at this time is an absolute priority for us.

There is currently no clear evidence to suggest that pregnant women are at a greater risk from COVID-19 than any other healthy individual or that they will pass the infection to their unborn baby while they are pregnant. However, we are still learning more about how this virus affects pregnancy and therefore we advise pregnant women to be cautious and to minimise the risk of catching the virus.

COVID-19 vaccination

The Joint Committee on Vaccination and Immunisation (JCVI) has advised that pregnant women should be offered COVID-19 vaccines at the same time as people of the same age or risk group.

Booking a vaccination
You can book or manage your COVID-19 vaccination through the national booking system
Changes to our maternity services

Our maternity services are also making changes to help respond to coronavirus and protect our patients staff and visitors. We would like to reassure you that we are taking extra care in how we are looking after all women who come into our services to make sure they stay safe.

We have created separate areas and are following government guidance to care for those who have or are suspected to have COVID-19. This ensures that those women who are unaffected are also kept safe and well. As a precaution, you should follow government advice about social distancing; stay away from public places and avoid anyone who has symptoms suggestive of COVID-19.

In addition, there will be some key changes to our maternity services as follows:

Re-introduction of partners to some of our maternity services

In line with national recommendations, the maternity service at the Royal Free London ceased all non-essential visiting in March 2020. We are now pleased to inform you that we are in a position to lift some of these restrictions. This will be done in phases and subject to some important conditions, and we will continue to monitor the impact of these changes.

Your partner will be able to join you 24 hours a day on our antenatal wards if you are in early labour or having your labour induced.

One consistent partner (the same partner as in labour) will be able to visit you for a period of four hours on our antenatal wards and postnatal wards (5 South at the Royal Free Hospital and Victoria ward at Barnet Hospital).

One partner will be able to attend antenatal clinic and early pregnancy clinic visits.

One partner will also be able to accompany all antenatal scans and early pregnancy unit scans.

Children are not permitted to visit maternity or ultrasound areas at the current time.

Please note, in order to adhere to government guidance on social distancing, we're unable to reintroduce visiting in the following areas: triage, antenatal clinics, maternity day assessment unit.

Your partner will be screened each time they enter a maternity service. If at any time your partner experiences symptoms of coronavirus or presents with a positive COVID-19 screening, they will need to stay at home and self-isolate. Read the full details in our information leaflets:

Antenatal appointments

We will contact you to discuss any changes to your upcoming appointment. If we make any changes to your upcoming appointment we will telephone you, otherwise please attend as planned.

We may offer you a telephone or video appointment to replace your face-to-face appointment, but we will discuss this with you first.

Glucose tolerance test appointments will still be held in hospital. If you have a glucose tolerance test scheduled, please come to hospital for your appointment.

If you or a member of your household has any symptoms of COVID-19 or are self-isolating, do not attend your routine appointments or come to the hospital. If you live alone, appointments can be postponed by 7 days. If you live with others, in line with the government's recommendation this should be 14 days.

To cancel or postpone your appointment, please telephone our call centre on 020 3758 2022 (open 9am-4pm, Monday to Friday) and if you have any questions you can ask to speak with a midwife or doctor.

If you have symptoms of COVID-19, and are unwell, or require urgent medical advice, please call the labour ward helpline numbers below:

Labour ward 24-hour helpline

Barnet Hospital: 020 8216 4408

Royal Free Hospital: 020 7794 0500 extension 33850/33849

Scans

We are continuing to offer ultrasound scans at 12 weeks and 20 weeks at present, so if you have a 12-week or 20-week scan scheduled, please come to hospital for this as planned.

We will continue to arrange additional scans where clinically necessary and your doctor or midwife will tell you if this applies to you.

Please be advised, if you are due to attend an antenatal or ultrasound appointment at the hospital, please do not attend:

if you or someone you live with is experiencing any of the following symptoms; a new continuous cough or high temperature.

if you or someone you live with is currently in self-isolation.

If the above applies to you, please contact the maternity call centre on 020 3758 2022 and select option 4.

Antenatal classes and tours

There are also multiple mobile apps that provide helpful information about pregnancy, birth and parenting. The 'Baby Buddy' app is very popular and free.

What happens if I go into labour during my self-isolation period?

If you are in self-isolation and think you are in labour, please contact your maternity unit for advice. If you are planning to give birth at the Royal Free Hospital, please call the labour ward helpline on 020 7794 0500 extension 33850/33849. If you are planning to give birth at Barnet Hospital, please call 020 8216 4408.

Please let us know if you have suspected or confirmed COVID-19 or if someone in your household is affected. If your symptoms are mild, they will encourage you to stay at home in early labour, which is standard practice.

When you and your maternity team decide you need to attend the maternity unit:

You will be advised to arrive via private transport where possible.

Someone will meet you at the entrance to give you a mask, which you need to keep on until you are in a room.

COVID-19 testing will be arranged for you.

Home birth services and the Edgware Birth Centre

The Royal Free London has reinstated home birth services and reopened Edgware Birth Centre.

If you would like more information about the centre/options on where you can give birth, please contact your midwife.

You can also find more details about Edgware Birth Centre including contact details here. Further information about our home birth services can be found here.

What to expect when you get home after you have given birth

Your midwife will call you the day after you are discharged to ask you how you and your baby are, to answer any questions you may have and to plan your care. If you do not receive a call by 3pm the day after you are discharged, please call the unit where you had your baby:

Barnet Hospital / Edgware Birthing Centre: 020 8216 4408

Royal Free Hospital: 020 7794 0500 ext 33850/33849

You can also call us on our maternity helpline: 0203 758 2022, option 4 (open Monday-Friday, 9am to 4pm)

Your midwife will visit you at home when your baby is five days old and telephone you after your baby's birth to check in and make a plan if you need further care. The health visitor will contact you between 10 and 14 days.

Before the midwife visits you, they will contact you to ask if you or any member of your househould has symptoms of COVID-19 (a fever and/or a new and persistent cough) or are self-isolating.

It is very important that you tell your midwife if you or a member of your household has symptoms or are self-isolating. Unless there is a pressing emergency, midwives will not be able to complete home visits until the last member of the family has completed their 7 days of self-isolating for symptoms, or 14 days if self-isolating for a household member with symptoms.

When your midwife visits you, to reduce the risk of COVID-19 transmission they will:

wear a mask, apron and gloves

ask to see only mum and baby, and in a separate room to other members of the household

maintain social distancing as far as possible leave the used apron, gloves and masks in a sealed orange bag in your house which can be disposed of after 72 hours in your normal household disposal

If you have any questions, please don't hesitate to contact the maternity team on one of the numbers above.

Before leaving the hospital you should have received a booklet titled ' Your postnatal maternity guide'. This booklet provides supplementary information about your recovery following childbirth, what to look out for as well as well as information about the care of your baby. It also signposts you and your family to other sources of information.

Feeding and caring for your baby

We have prepared information for you with regard to feeding and caring for your baby - please click here. This information provides details of useful resources that you can access online.

Maternity helpline

Please contact the maternity helpline in the first instance with any questions about your care. The maternity helpline team will answer your questions, or transfer you to another team if required:
020 3758 2022 and select option 4, available 9am-4pm, Monday to Friday

Please remember you can also call us on the labour ward helpline numbers (above) if you have any other general (non-COVID 19) concerns about your pregnancy. These include:

reduction in your baby's movements

vaginal bleeding

if your waters have broken

abdominal pain

Information from the NHS: Pregnancy and coronavirus

NHS.uk has dedicated information about pregnancy and coronavirus here: www.nhs.uk/pregnancy-and-coronavirus

The following information leaflets are available on their website:

Planning your birth

Looking after yourself and your baby in pregnancy

Parent information for newborn babies

Useful resources

Thank you for your understanding and support

We remain committed to providing you with outstanding care and have dedicated staff working hard to ensure you have a safe and positive pregnancy and birth. Our maternity staff will remain working at the hospital to care for you and your baby throughout the antenatal, labour and postnatal periods. There may be times when less staff are available than usual, but we have an extra layer of midwives and doctors on duty 24 hours a day to provide support.
Our top priority is to provide the best service we can for you and we thank you for your understand during this challenging time and your support in helping us to keep you, your family and your baby safe.

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COVID-19 (coronavirus): Information for maternity service users

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NHS Guidance: Pregnancy and your risk from COVID-19 COVID-19 (coronavirus) information for maternity patients planning to give birth at the Royal Free London NHS Foundation Trust London We would like to take this opportunity to update you about your maternity care at the Royal Free London during the COVID-19 (coronavirus) pandemic and reassure you that yours and your baby's safety at this time is an absolute priority for us.

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Our Response to the Ockenden Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust

Too few staff

Lack of ongoing training

Lack of effective investigation of incidents

Not listening to women and families

The report highlighted the ways in which maternity services nationally could learn from what happened at Shrewsbury and Telford and Whittington Health NHS Trust would like reassure you that we take this report very seriously.

We have a close working relationship with the Whittington Maternity Voices Partnership and value contribution that parents to be and families can bring when reviewing and developing our maternity services. It is important that we listen to all women and put their voice at the centre of our care.

As a result of the report, we have started work with Maternity Voice Partnership (the Whittington MVP), the North Central London Local Maternity System and NHS England to look at our maternity services to review and implement the recommendations contained within the report.

We take the views of everyone giving birth with us very seriously.

During the pandemic we did experience staff shortages due to sickness and currently do have vacancies for Midwives and support workers which are being recruited to. Our staff are trained to the highest standard and undergo regular professional and training updates. All of incidents are thoroughly investigated using a clear and open process, these are discussed and shared with our Maternity Voice Partnership.

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Too few staff Lack of ongoing training Lack of effective investigation of incidents Not listening to women and families The report highlighted the ways in which maternity services nationally could learn from what happened at Shrewsbury and Telford and Whittington Health NHS Trust would like reassure you that we take this report very seriously.

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Statement

The Unicef UK Baby Friendly Initiative has received a number of queries regarding best practice for infant feeding during the Covid-19 outbreak. We suggest that all practitioners follow latest updates from the UK governments and the World Health Organization (WHO) (see Clinical management of severe acute respiratory infection, currently page 13). Note: these documents could change as more information becomes available.
Breastfeeding
There is a wealth of evidence that breastfeeding reduces the risk of babies developing infectious diseases. There are numerous live constituents in human milk, including immunoglobulins, antiviral factors, cytokines and leucocytes that help to destroy harmful pathogens and boost the baby's immune system. There is no evidence at this time that Covid-19 can be passed through breastmilk. Therefore, considering the protection that human milk and breastfeeding offers the baby and the minimal role it plays in the transmission of respiratory viruses, it seems sensible to do all we can to continue to promote, protect and support breastfeeding.

To facilitate breastfeeding, mothers and babies should be enabled to stay together as much as possible, to have skin-to-skin contact, to feed their baby responsively and to have access to ongoing support when this is needed.

When mothers are partially breastfeeding, they can be encouraged to maximise the amount of breastmilk they are able to give or, if they choose, to be supported to return to full breastfeeding. If mothers are considering stopping breastfeeding, it is worth having a sensitive conversation about the value of continuing during the Covid-19 outbreak.
Formula feeding
Parents should be encouraged to continue adhering to current guidance on washing and sterilising equipment. Parents should be supported to bottle feed responsively, including pacing feeds and limiting the number of people who feed their baby.
Practical information for parents if they have Covid-19 and are caring for their baby
If parents/carers are infected, take precautions to limit the spread of Covid-19 to the baby by:

Washing hands thoroughly before and after contact with the baby.

Routinely cleaning and disinfecting any surfaces touched.

Cleaning any infant feeding equipment, including breast pumps, bottles and teats thoroughly before and after use.

Practicing respiratory hygiene, including during feeding, for example by avoiding coughing or sneezing on the baby and by wearing a face mask or suitable alternative if available.

Parents should take care to avoid falling asleep with their baby, see Co-sleeping and SIDS, Safer sleep for babies.

If a breastfeeding mother is feeling unwell, continuing breastfeeding rather than expressing may be easier and less stressful during this time. Alternatively, she may prefer for someone who is well to feed expressed breastmilk to the baby.

If the mother is too unwell to breastfeed or express breastmilk, she may be supported to re-lactate once well enough. Consider using donor milk if available and applicable.

If a baby is being bottle fed with infant formula or expressed milk, wash equipment in hot, soapy water and sterilise carefully before each use.

Accessing infant formula
There were reports of parents being unable to purchase infant formula, but at time of writing this seems to be improving. We have been informed that retailers do have stock and are limiting purchases of infant formula to 2-4 tins per customer. However, we are unsure if supplies are consistently available across all parts of the UK and whether the current situation will change as the Covid-19 outbreak progresses.

Currently, parents should be advised that stage 1 / first infant formula should be used for infants in the first year of life:

If parents are unable to get their usual brand of first infant formula, they can use any first infant formula as all preparations have a similar nutritional composition to comply with legislation.

Parents should be advised not to use stage 2 follow on formula for any baby under 6 months - only use first infant formula.

If parents are using follow on formula for a baby older than 6 months and cannot access this, then they can use first infant formula.

If parents are using other milks such as anti-reflux milk, comfort milk, etc. and can't access these, they can use first infant formula.

Advise parents to always make up infant formula as per manufacturer's guidance and not be tempted to add more water to the feed to make it last longer, as diluting the milk could endanger the baby's health.

There are reports that the number of families applying for universal credit has dramatically increased during the first weeks of the Covid-19 outbreak. Families in receipt of universal credit are entitled to Healthy Start vouchers. Supporting families to claim their vouchers will enable them to access infant formula.
Supporting close and loving relationships
Regardless of feeding method, it is essential that babies' needs for emotional attachment with their parents / primary caregiver continues to be considered. Keeping babies close and responding to their need for food, love and comfort are all essential for babies' health, wellbeing and development. In addition, this will enhance the mother's mental wellbeing in the postnatal period.
Additional information
A range of Baby Friendly resources on infant feeding and supporting close and loving relationships can be found at: Unicef UK Baby Friendly Initiative

Telephone support for parents: National Breastfeeding Helpline 0300 100 0212 from 9:30am to 9:30pm, 7 days a week. Live online support via web chat.

Information on infant formula can be found at: First Steps Nutrition Trust

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Infant feeding during the coronavirus (Covid-19) outbreak - Baby Friendly Initiative

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The Unicef UK Baby Friendly Initiative has received a number of queries regarding best practice for infant feeding during the Covid-19 outbreak. We suggest that all practitioners follow latest updates from the UK governments and the World Health Organization (WHO) as these could change as more information becomes available.

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free images to download

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The Positive Birth Book Visual Birth Plan

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We now have a fantastic free website where you can choose from all the visual birth plan icons from The Positive Birth Book by Milli Hill, or create your own bespoke icons, to create a personalised visual birth plan (VBP) that you can then download and share with your care providers as you make decisions about your bir

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information for your doctor, perhaps

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Abstract

Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a 'natural' approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide.

Please cite this paper as: Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037-1042.

Keywords: Bonding, caesarean section, natural childbirth, physiological resuscitation, skin-to-skin contact

Introduction

The management of vaginal birth has changed hugely in the 15 years since woman-centred maternity services were recommended in the Department of Health's Changing Childbirth report. Caesarean rates doubled during the same period; yet, abdominal delivery has changed little, apart from occasional background music and a safety-led shift from general to regional anaesthesia.

If promoting what is natural underpins the modern management of vaginal birth, the need for speed and resuscitation remain the principles governing techniques for caesarean birth today. Surgical rapidity, however, is unnecessary in the absence of fetal compromise, and a throwback to the days when general anaesthesia was the norm, with short induction-delivery intervals advocated to reduce fetal anaesthetic exposure and the subsequent need for resuscitation. Although paediatricians are no longer required at straightforward caesareans under regional block, the baby is usually taken to a Resuscitaire, examined, cleaned, tagged, weighed and swaddled before being introduced to the parents, often a good 10 minutes after birth. Early skin-to-skin contact and initiation of breastfeeding within 30 minutes as recommended by the WHO/UNICEF Baby Friendly Initiative, is almost nonexistent.

Increasing evidence shows that women undergoing caesareans have a less satisfactory childbirth experience than those delivering vaginally and are more prone to postnatal depression, bonding difficulties and unsuccessful breastfeeding., To improve the experience of women having uncomplicated caesareans, we have modified obstetric, midwifery and anaesthetic practice over the past 6 years to emulate as closely as practicable the woman-centred aspects of 'natural' vaginal birth.

Technique

We describe a technique for straightforward elective caesareans in healthy women with non-compromised singleton fetuses at term. It can be adapted for nonurgent emergency procedures but is not suitable for preterm or breech presentations.

Preparation

Antenatally, we use video clips to demonstrate what happens at a 'natural' caesarean. When possible, the woman (and her partner) meet the midwife and obstetrician preoperatively and are shown the operating theatre to render the environment less intimidating. The couples are encouraged to bring their own music, and the woman can wear her own clothing if she wishes.

In theatre, the pulse oximeter is positioned on the mother's foot to keep her hands free, and the electrocardiogram (ECG) leads away from her anterior chest wall where the baby will be placed. The anaesthetic block aims to permit pain-free surgery without requiring supplementation (which may obtund the woman's responses). It should not affect the upper limbs needed to hold her baby nor cause haemodynamic instability with its potential for light-headedness, nausea or vomiting. The intravenous line is placed in the nondominant arm as per usual practice. We use a combined spinal-epidural needle-through-needle technique with 7.5-10 mg bupivacaine intrathecally and a prophylactic infusion of the vasopressor phenylephrine. Once the block is sited, one of the woman's arms is freed from her clothing to facilitate skin-to-skin contact. Cardiotocography is continued until skin preparation to confirm fetal wellbeing.

Delivery: walking the baby out

Surgery starts with the screen up, and sterile routines observed as usual. After uterine incision, the drape is lowered and the head of the table raised to enable the mother to watch the birth. As the fetal head enters the abdominal incision, the operative field is cleaned of blood and the partner is invited to stand to observe the birth. The principle for the surgeon is then hands-off, as the baby autoresuscitates: breathing air through the exteriorised mouth and nose, while its trunk still in utero remains attached to the placental circulation. This delay of a few minutes allows pressure from the uterus and maternal soft tissues to expel lung liquid (), mimicking what happens at vaginal delivery. Once crying, the baby's shoulders are eased out, and the baby then frequently delivers his/her own arms with an expansive gesture. Concurrently, the baby's torso tamponades the uterine incision, minimising bleeding ().

The baby is next left supported for up to a minute, allowing the mother to observe her child. The half-delivered fetus frequently cries but if not, the obstetrician observes its breathing, colour, tone and movement to indicate wellbeing. The rest of the delivery is achieved through a combination of passive expulsion by the contracting uterus and active assistance: the baby wriggles out while its head and torso are supported by the obstetrician. This enables the mother to watch the birth and ascertain the sex of her baby at the same time as the delivery team, replicating the situation at vaginal birth ().

Early skin-to-skin contact

Once the baby is finally 'born' and wellbeing again confirmed, the cord is clamped and cut in view of the parents. The anaesthetist/anaesthetic assistant clears the mother's clothing from her chest, and the midwife positions him/herself at the top of the bed beside the mother's head. Still scrubbed, the midwife receives the baby directly from the surgeon to prevent contamination (). The woman should be warned not to reach out for her baby, as this risks touching the obstetrician. The baby is laid prone between the mother's breasts, dried with a warmed towel and kept warm with fresh towels and bubble wrap.

After a plastic clamp is applied, the partner can cut the remaining cord if he wishes. Labelling and vitamin K administration are accomplished with the baby on the mother's chest. The baby is positioned so that he/she can begin to suckle. The midwife remains near the head end to monitor the baby and reassure the parents. The baby is only weighed when surgery is finished, and given to the partner while the mother is transferred to her bed. Skin-to-skin contact is then re-established with the baby in the same position.

Discussion

Caesarean section remains entrenched in hospital routines, seemingly immune to the tide of customer-focused changes that has swept maternity services and labour ward care. The 'natural' caesarean technique we describe has evolved as a series of measures to mimic the situation at vaginal birth, where birth attendants encourage early skin-to-skin contact, facilitate physiological resuscitation, but most of all, engage the parents as active participants in the birth of their child.

Randomised trials demonstrate that early skin-to-skin contact increases the rate and duration of breastfeeding, reduces infant crying and improves maternal affection. Although recommended by both the Royal College of Nursing and National Institute for Clinical Excellence,, this has hitherto proved refractory to implement at caesarean section against a background of ritualised obstetric and midwifery routines. We describe how immediate skin-to-skin contact can be established at straightforward abdominal delivery without compromising operative sterility.

Respiratory complications like transient tachypnoea of the newborn are more common after elective caesarean than vaginal delivery, ⁻ in which retained lung liquid is implicated, as is the lack of catecholamine and cortisol surge associated with vaginal birth. Pausing the delivery of the baby, as shown in , to allow physiological expulsion of lung liquid like at vaginal delivery may facilitate respiratory adaptation.

We report the technique at this stage in the absence of quantitative outcome data in response to frequent requests from obstetricians and women, and considerable media interest. In qualitative terms, the natural caesarean has been positively received by the couples involved (Supplementary material S1), with no adverse comment in more than 100 procedures. One fear that women expressed preoperatively was the possibility that they would see inside their own abdomen. We explain that the baby's head 'blocks the hole' and once baby is delivered, the screen goes back up. In reality, maternal position precludes this anyway. Formal audit of maternal and fetal outcomes is now indicated, with a view to eventual randomisation. We offer the following observations on introducing this package of measures.

Fetal safety is paramount, and we immediately resort to routine management if the baby is unexpectedly born in poor condition. The uterine incision-to-delivery interval is prolonged compared with routine practice, but usually still within the 3 minutes formerly recommended for optimal neonatal condition. However, during this period with the head out but the trunk still inside, not only is the crying baby establishing a resting lung volume but also the placental circulation remains intact. Experience with the partially exteriorised fetus during EXIT (Ex utero Intrapartum Treatment surgery to establish the neonatal airway) procedures suggests that fetal oxygenation can be maintained over much longer intervals, the largest series showing an average cord pH of 7.20 after a median of 17 minutes on 'placental bypass'. Because birth is timed when the baby is completely expelled from its mother's womb, natural caesarean babies often achieve a healthy Apgar score before they are actually born.

Thermal care warrants attention. Although neonates undergoing skin-to-skin contact after vaginal birth are no colder than those who do not, the theatre environment is different from that of a labour room. Air conditioning may increase heat loss through convection drafts, even when ambient temperature is maintained. Following conventional delivery, the baby is routinely placed under the radiant heat of the Resuscitaire before being swaddled. We warm and cover the baby on the mother's chest and maintain theatre temperature ≥25°C.

To establish that the mother's chest is a safe place for the baby while the woman is undergoing surgery, we ensure that the mother wishes to have the baby there and is in a fit state to do so. We request that the partner helps support the baby, and an important practice point is that the midwife remains at the head end after delivery, as the anaesthetist is busy at this juncture. The operating table should be levelled from the preoperative lateral tilt. An unanticipated problem was that the maternal ECG sometimes picks up the baby's heartbeat as he/she lies on the mother's chest, mimicking a potentially alarming maternal tachycardia.

Perhaps, the biggest obstacle to implementation is reluctance of staff to change roles and give up rituals. A multidisciplinary team approach is key. The surgeon cannot remain aloof behind the drape. The anaesthetic team must embrace the presence of the baby at the 'head-end', and midwives need to accept that what is good practice at a vaginal birth is also achievable in theatre. An initial midwifery concern that the technique would delay a busy operating list, with no opportunity to weigh, check and dress the baby or complete the paperwork until the end of the operation, was assuaged once the staff had witnessed the family friendly benefits of a 'natural' section.

Caesarean section rates are rising worldwide, and indeed, now exceed one-third of deliveries in many developed world centres such as our own. Given the negative effect that caesareans, whether indicated or discretionary, have on maternal satisfaction, bonding and breastfeeding, improving this experience while maintaining safety should be a priority. We describe an evolving approach, suitable for global export. Studies are now indicated on the effects of naturalising this most unnatural form of birth.

Editor's Commentary

Peripartum care of women and their babies has changed dramatically over the previous half century. While the evolution of prenatal diagnosis and fetal monitoring, safer anaesthesia, and improved surgical techniques have continued to improve and optimise perinatal outcomes, this progressive 'technicalisation' of the birth experience has also resulted in many ultimately unnecessary interventions as well as frequent dissatisfaction among women and their families with the institutionalised birth process. Many developed world medical centres have responded with various 'woman-friendly', 'family-friendly' and 'baby-friendly' initiatives, all with the intentions of optimising outcomes and satisfaction for mothers and babies, promoting bonding and breastfeeding, and minimising risks for all involved. These 'friendly' initiatives are predicated on healthy mothers and healthy babies, generally assuming the spontaneous onset and normal progression of labour at term and have been carefully monitored to ensure that outcomes are truly optimised (Waldenstrom and Nilsson, Birth 1997;24:17-26; Jackson et al., Am J Public Health 2003;93:999-1006).

While these initiatives have often been instituted by medical centres reactively rather than proactively, they have performed much to promote what is truly natural in human labour and delivery. Now, however, the worldwide caesarean epidemic is seen by many women as a further threat to their ability to safely and humanely deliver their babies. The group from Queen Charlotte's and Chelsea Hospital describe a surgical technique in this issue that has, by their report, evolved in their institution over the past few years in an attempt to improve the experience of women having 'uncomplicated' caesarean births.

The authors are to be commended for their caesarean birth preparation activities. While this can do much to enhance acceptance by women and their partners of caesarean birth, it should not be assumed that caesarean birth is 'natural'. There is impressive evidence that the risk of serious intraoperative complications increases with the number of previous caesarean births (Silver et al., Obstet Gynecol 2006;107:1226-32) and I hope that the option of a trial of labour would also be presented fairly in this setting.

Most importantly, however, no outcomes or safety data are presented to justify widespread utilisation of this technique. While this is acknowledged by the authors, it is critically important that readers understand this. We should demand that these techniques be adequately studied with appropriately powered clinical trials and meaningful outcomes. The history of clinical medicine is littered with examples wherein new approaches were adopted wholesale without adequate evaluation, only later to be found to be of no benefit or to have added increased risks. The reality is that protocols such as described here are evolving in many centres around the world, and it is imperative that they be adequately evaluated.

BJOG has a tradition of publishing controversial techniques (Chien, BJOG 2006;113:988). Constructive controversy, and the resultant dialogue, is good for everyone and generally accelerates improvement in techniques and outcomes. We look forward to clinical trials that evaluate the changing techniques of caesarean birth.

Acknowledgments

The authors acknowledge support from the National Institute of Health Research Biomedical Research Centre funding scheme.

Conflict of interests

N.M.F. undertook private obstetric practice (for institutional gain) until November 2007. N.M.F. is on the Obstetric Advisory Board of Ferring UK.

Contribution to authorship

N.M.F. conceived the initial idea, which was then developed, implemented and improved with J.S. and F.P. All three jointly wrote and approved the final manuscript. N.M.F. acts as guarantor.

Ethical approval

Approval was not required. This paper is a description of a technique that evolved over many years in response to patient demand and national guidelines. No end-points were recorded, and as with the many other 'soft' variations in routine surgical, obstetric and midwifery care, such practice does not come under the World Medical Association Declaration of Helsinki definition of human experimentation. Informed consent for caesarean section was personally obtained by the senior author and included showing video clips of the natural caesarean technique, discussion of the optional nature of the 'walking the baby out' component and the monitoring of fetal/neonatal wellbeing undertaken by N.M.F. as surgeon.

Supplementary material

The following supplementary materials are available for this article:

Appendix S1

Patient experiences of "natural caesarean".

These materials are available as part of the online article from: http://www.blackwell-synergy.com/doi/abs/10.1111/j.1471-0528.2008.01777.x.

(This link will take you to the article abstract).

Please note: Blackwell Publishing is not responsible for the content or functionality of any supplementary materials supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

References

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The natural caesarean: a woman-centred technique

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Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding.

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Caesarean births have risks and benefits. From planning a repeat caesarean and writing a birth plan to coping with disappointment and c-section recovery, we have the information. - BabyCentre UK

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Obstetric consultants often take the results of growth scans as gospel, scheduling elective C-Sections or inductions as a result of them, but how accurate are these estimates? and does early induction or elective C-Section really prevent problems if a baby is extra large? - you might be surprised at the answer!

Ultrasound is widely believed to be the most accurate method of estimation of foetal weight. Yet in 1988, Miller, Brown, Khawli, Pastorek & Gabert in "" found that the typical mean error ranges from 300 to 550g (11.6 to 19.4 oz). That's around a WHOLE POUND! In 1992 Chauhan, Lutton, Bailey, Guerrieri & Morrison In "' " found that ultrasound was the least accurate of the three methods, i.e: it was less accurate than the educated guess of the obstetrician or mother! In their study "" Delpapa & Mueller-Heubach found that "" - That's quite some difference!

If you believe the media you will probably think it is because we all eat too many chips. In reality there's an awful lot more to it than that. It is true that women who develop Gestational Diabetes are more likely (a twofold risk in fact) to give birth to a larger infant, however this site is interested in those women who have not been labelled with any medical disorder and who seem to "just make big babies". There are several known risk factors, aside from Gestational Diabetes, which can highlight certain women who are more predisposed to birthing a macrosomic baby, these are:

The female pelvis is PERFECTLY designed for birth.....no matter the size of the baby.....it is designed to open up to make more space for the baby.......and a baby's head is PERFECTLY designed to gently mould, to make it smaller, so that it passes through the female pelvis with ease. Babies know how to get into a good position for birth, tucking their head tightly so that the smallest part presents first.

The size of a baby then in a normal, physiological birth - where anxiety and "big baby" talk is not present - is largely irrelevant, it doesn't make it more painful and it doesn't make it harder! The following article, by midwife Gloria Lemay, is a MUST read for anybody worrying about birthing a large baby and wondering whether their pelvis is "big enough"

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Big Babies - The Curse of (mis) Diagnosing a Macrosomic Infant Part.1

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Thousands of women are diagnosed with suspected big babies (or 'macrosomia' to use the medical terminology) every year, but this one simple label can have a profound effect on their birth. Obstetric consultants often take the results of growth scans as gospel, scheduling elective C-Sections or inductions as a result of them, but how accurate...

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Maternity Services Bridgend, Tirion Birth Centre & Merthyr

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Corona virus info

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If you are pregnant, you may be concerned about how coronavirus or COVID-19 (the illness resulting from coronavirus) will affect your rights to maternity care, if cases increase significantly as expected.

The NHS has general information on its website about coronavirus. The Royal College of Obstetrics and Gynaecology (RCOG) has information for pregnant women and their families on its website, which will continue to be updated.

The relevant Royal Colleges (the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives and the Royal College of Paediatrics and Child Health) have also published this information for maternity healthcare professionals.
Will I still receive maternity care as normal?
You will still receive maternity care. However your care might be slightly different to what you expected. For example, more appointments may be conducted over the phone, if you don't need to be seen in person. If you have been advised to self isolate, then routine appointments, including scans, may be delayed until after your isolation period.
Will I have to accept changes I am not happy with?
Maternity services should still treat you with dignity, and you can always decline any intervention/treatment you are not happy with. However in some cases Trusts may have to make changes to the services they offer. The law allows them to do this, even if it means restricting choices, if they can show that it is a proportionate response to the challenge of coronavirus.
I have been planning a home birth, will I still be able to have one?
Yes, if the Trust has enough staff to run this service.

Official guidance recommends that women who have (or may have) COVID-19 give birth on an obstetric unit with continuous fetal monitoring (CTG) and increased maternal monitoring (e.g. oxygen monitoring). However, the fetal monitoring advice is based on a very small sample of births in Wuhan, China, where there was a higher than usual rate of babies being distressed during labour. It is not clear at present whether this was linked to COVID-19, as the sample size was very small, so this advice is only a precaution.

If the Trust are not able to offer a home birth, they should be able to give a good reason why coronavirus has changed their ability to offer a home birth, and to offer alternatives such as birth in a midwifery-led birth centre, where possible.
I am due to have an elective caesarean, will this still go ahead?
Yes. Obviously there is a limited timescale in which caesareans can be scheduled, and therefore caesareans, even if elective, will need to go ahead. There may be a need for some re-scheduling, as services prioritise. If you have, or may have COVID 19, special precautions, e.g. protecting staff with special masks, will be in place.
I am due to have a maternal request caesarean, will this still go ahead?
Yes, unless the Trust can give a good reason why the Trust cannot honour that commitment due to the changed circumstances. Caesareans will be prioritised according to clinical need but Trusts should be doing their best to follow NICE guidance, and to undertake all caesareans on their lists, even if some re-scheduling is required.
Will I still have continuity of care?
Each Trust will have to continue to monitor if it has sufficient staff to offer its usual service, and to make short-term alternative arrangements to see a midwife or doctor even if not your usual one.
Will I have one to one care in labour?
Each Trust will have to continue to monitor if it has sufficient staff to offer one to one care in labour, but it has a duty to offer a safe service at all times.
Will I still be able to have my birth partners with me?
The RCOG advise that you will still be able to have your birth partner(s) with you throughout but visitors should be kept to a minimum. Trusts that restrict a woman's right to choose who will be present at her birth, for example by restricting birth partners to one, will need to be very clear that this response is proportionate to the additional threat of infection. The case of birth partners should be looked at separately to other visitors, given their supporting role. If the Trust feels confident its response is proportionate, it should look at exceptions on a case by case basis, as a blanket policy could be open to challenge.

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Coronovirus - how will it affect my rights to maternity care? - Birthrights

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If you are pregnant, you may be concerned about how coronavirus or COVID-19 (the illness resulting from coronavirus) will affect your rights to maternity care, if cases increase significantly as expected. The NHS has general information on its website about coronavirus. The Royal College of Obstetrics and Gynaecology (RCOG) has information for pregnant women and ...

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Will I give birth alone? (short answer: no)

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"Will I give birth alone?" is one of the key questions being asked by pregnant women and birthing people as hospitals adapt their policies to minimise the spread of Coronavirus.

As a doula, I'm an additional birth supporter, working with partners and midwives and medics to create a support team around the mother or birthing person. I recently supported a birth in London as the only birth partner where a family member had self-isolated, and where it was treated as a suspected Covid-19 case - the first the hospital was dealing with. (Article updated 12/5/20 to reflect new UK hospital policies and RCOG guidance)

Many hospitals in the UK are changing their guidelines and restricting the number of people coming into the building - surgery is being cancelled, visitors restricted to one or none. Doula Lauren Mishcon shared this analogy: 'remember the photos of the firemen running into the twin towers as everyone was running out? That's the medics right now'. Birthing in a pandemic wasn't in your birth plan, so what changes can you expect?

Guidelines are changing daily as more is becoming known about the spread of Coronavirus. The guidance for pregnant people in the UK is (as of 17th April) on version 8. And this is only two months since version 1 was published. People giving birth are generally being asked to bring only one supporter who must not have symptoms (this varies by Trust as each can make its own decisions) and can stay for a short time after the birth. Of course, this guidance may change again to limit the spread of Coronavirus even more. Antenatal and postnatal services are moving to online or phone consultations where possible. Staying in hospital after a birth is being reduced to the minimum safe times, for example to 24 hours after an uncomplicated caesarean and to 3-6 hours after a straightforward vaginal birth with partners not being allowed on most antenatal or postnatal wards or for scan appointments.

Apart from the small number of births each year that are so sudden that neither a midwife or paramedic can get to you, or where you can't get to a hospital, you will not birth alone. Labour support is the priority of the midwifery services even in a crisis, so even if you don't have your expected birth partner(s) with you due to their symptoms, you will be cared for by a midwife whose job it is to support you through your labour and birth. At the moment Trusts in the UK are allowing one supporter for the birth. The Royal Colleges of Midwives, The Royal College of Obstetricians and Gynecologists and the World Health Organisation have issued guidance supporting the necessity of having a birth partner of choice for labour and birth, which is some reassurance to those giving birth in the UK.

This wasn't on your birth plan, and your partner, planned birth supporter or doula will be gutted not to be there physically with you if they have symptoms or hospital policies have restricted how many people can stay. But these rules will help to keep you and your baby safe from Coronavirus, and to make it possible for the midwife to support the next birth and the next.

You can expect to be treated with respect, kindness and compassion - human rights don't disappear in a crisis.

You can expect increased levels of infection control, with staff wearing masks, gowns or other protective clothing. This can make it harder to tell who everyone is, to hear them or to see facial expressions, so staff should be working hard to overcome these barriers.

You can expect a symptom-free partner or companion to be able to accompany you in labour and for the birth.

You can expect to be together with your newborn, unless one of you needs specialist medical care after the birth.

You can expect a shorter hospital stay (if you're birthing there), no visitors and reduced face to face contacts for appointments before and after the birth (although you should still be seen a minimum of 6 times face to face during your pregnancy).

Home births may increase or decrease, dependent on your hospital trust's staffing decisions. Home births keep people out of hospitals but the benefits have to be balanced with the lack of availability of ambulances to transfer to obstetric care if needed.

Planned elective caesarean births are currently going ahead in the UK, unless the Trust does not have the capacity to honour the commitment.

The charity Birthrights has published a great blog on maternity rights within the context of Coronavirus and are a source of support if you feel you are not being treated with respect and dignity.
"What can I do to plan ahead?"

"Are there any positives right now?"

Keep up to date with your hospital trust's current policies via their social media accounts, through your midwife or the local Maternity Voices Partnership.

Minimise all contact (social distancing) for you and those living with you by following government guidelines, self-isolation if you or someone you've been in contact with has symptoms, and good hygiene at all times.

Talk through your birth preferences with your midwife and birth partner/s. Think about what things are the most important to you and how these can be best achieved. Now is the time for plans A through to Z!

Find out what local online support there is for new parents - and make connections now to ensure you are supported after your baby arrives.

Consider whether sustainable parenting choices such as cloth nappies/wipes will be right for you to reduce reliance on shops.

Look into hiring a doula for phone and skype support, or as a back up for your partner if they are self-isolating or ill. Doulas are also volunteering with online support for many vulnerable or disadvantaged people so if cost is a barrier do ask about this.

Consider who else could be your birth partner if yours has to self-isolate.

Consider planning to breastfeed. Not only will it support your baby's health, there will never be a shortage of breastmilk at the supermarket. The Team Baby online learning course from the Association of Breastfeeding Mothers is a good place to start if you want to learn more.

Hospital services such as food outlets and restaurants are closed to the public (the birthing person will get meals), so for partners bring snacks and Pot Noodle style meals which can be made with hot water.

Phones, cables and portable charges have never been more important to pack if you own or can borrow these.

Take care of your mental health. It's really normal to feel anxious, and organisations such as the Maternal Mental Health Alliance have some great resources to help you cope.

This article is written in the author's capacity as a private doula. It does not constitute medical advice, and is not representative of the views of any voluntary organisation with whom she works nor any hospital Trust.

For people who are not self-isolating due to a family member with symptoms, and who don't have symptoms themselves, the main changes are around restrictions on the number of people you can have with you in hospital settings and in moves to online/phone appointments where possible. Having supported a birth recently, the biggest changes were around minimising the risks of infection with the use of masks and protective clothing for us and for staff, and changes to where things happened (for example not moving rooms after the birth to a postnatal ward). When we got home, some postnatal visits were conducted by phone instead of in person.

With groups moving online, there is a groundswell of support for expectant and new parents, along with a feeling of all being in it together which may help tackle the isolation new parents often feel. Extended homeworking means that partners may be around and able to flexi their time well beyond the statutory 2 weeks paternity leave usually offered. Being encouraged to labour at home for as long as possible and/or birth at home is likely to lead to less intervention in birth, giving a long-lasting reminder of the benefits of birthing without interruption and showing the midwifery profession's core skills of supporting physiological birth. And with no known increased infection risks to pregnant people compared to the general population, and because in all known cases of newborns with Covid-19 the baby remained well, the biggest positive will be the birth of your baby - just don't name them Corona!

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"Will I give birth alone?" is one of the key questions being asked by pregnant women and birthing people as hospitals adapt their policies to minimise the spread of Coronavirus. As a doula, I'm an additional birth supporter, working with partners and midwives and medics to create a support team around the mother or birthing person.

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If you're only going to read one book...

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If you're only going to read one book...

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Ina May's Guide to Birth

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Bantam Doubleday Dell Publishing Group Inc

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Ina May’s Guide to Childbirth By Ina May Gaskin | Used | 9780553381153 | World of Books

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Buy Ina May’s Guide to Childbirth By Ina May Gaskin. Available in used condition with free delivery in the UK. ISBN: 9780553381153. ISBN-10: 0553381156

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translated into a host of languages

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It's really important that women and birthing people and those that care for them, understand basic birth rights in maternity care. It is vital that conversations that lead to decisions, start from a shared understanding of what an individual can or can't choose to do and the obligations on maternity services to uphold human rights.

We have translated your basic birth rights into 16 languages. All PDFs hosted below are also available for print and download - just click the button next to the language you wish to access.

The factsheets were professionally translated and reviewed by native speakers, including in as many cases as possible, women involved in refugee and asylum support. We are also grateful to the Happy Baby Community for their support in making these factsheets a reality, and the National Lottery Community Fund for generously supporting the project.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
Do you work with pregnant women and birthing people?

Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Your basic birth rights - translated - Birthrights

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It's really important that women and birthing people and those that care for them, understand basic birth rights in maternity care. It is vital that conversations that lead to decisions, start from a shared understanding of what an individual can or can't choose to do and the obligations on maternity services to uphold human rights.

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A birth partner gives practical and emotional support when you're in labour. Here's how to get your loved ones involved in the birth of your baby. - BabyCentre UK

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Kingston and Richmond NHS Foundation Trust

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Scar after caesarean

When a scar is formed, fibres are laid down in many directions. These fibres can sometimes stick (''adhere'') to surrounding tissues. For a few people, too much scar tissue (also called "adhesions") can form and leave the scar feeling tight and sore.

Following a caesarean, too much scar tissue around the operation scar is often described as a pulling and tugging sensation. This can make daily activities and sex uncomfortable and may affect bladder and bowel function. It can also slow the recovery of your tummy (abdominal) muscles and contribute to backache. ​​​​​​​

Scar massage can help recovery

Once your scar has fully healed, your midwife may suggest you massage it. Scar massage is simple and aims to break up the scar tissue. This can reduce any itching and swelling and improve its appearance.

Not much research has been done to find out how well this massage works, but some people find it helpful.

When to start

If you feel comfortable and ready, you can start massaging your scar once your wound has fully healed. There should be no scabs or openings left. Scars are usually fully healed 6 to 8 weeks after a caesarean birth. If you are unsure, check with your health visitor, midwife or GP before starting any massage.

It is important to get the timing right. Massaging your scar too soon could cause it to reopen or tear, leading to an infection. But it is never too late to start.

How to do the massage

It is normal to feel a pulling or burning sensation when you start massaging your scar. Increase the pressure gradually and spend a couple of minutes on each technique. You may find it easier to massage your scar whilst having a bath, or try after a shower using any oil of your choice (if you are not allergic).

If you get any pain whilst massaging your scar, stop and leave it for a few weeks. Then come back to it. If the pain persists, speak to your GP.

Feeling your scar

Your scar may feel sensitive or tender. Or you may have less sensation or even numbness in some areas.

When you first start the massage, it may help to touch the surrounding skin without touching the scar itself. Try tracing small circles with your fingers, or moving the skin around. Then gently move towards the scar itself. If the skin is particularly sensitive, try all this with a cotton ball at first.

The scar tissue is not limited to the scar. So it is important to work around the scar too.

When you feel comfortable doing so, you can move on to massage the scar.

Massage your scar with the pads of 2 or 3 fingers together

Circle: make circular movements above, below and on the scar itself, if you can tolerate it. Repeat clockwise and anti-clockwise, 5 to 10 times.

Vertical: Pull across the scar, up and down, with short then longer strokes. Repeat 5 to 10 times.

Left and right: rest your hand or fingers on your scar and encourage your scar to move left and right (along the scar) for 10 to 15 secs. Then using your other hand encourage it in the opposite direction.

Pinch some tissue around or on the scar then roll the pinched skin up and down and side to side for about 10 to 15 seconds. Move along the entire length of the scar, repeat every 1/2 inch to 1 inch.

How often

We recommend doing theses stretches at least 4 times a week. At first, do it for 5 to 10 minutes each time. Then, when it feels less uncomfortable and the scar movement increases, you can gradually reduce how often you do it. Scar tissue continues to form for up to 2 years after an injury or surgery so regular massage is a good idea.

When to get advice

Remember to be kind and patient with yourself. Birth recovery is about caring for your body as well as processing your birth experience. If you are having difficulties with this, you can contact a healthcare professional such as your midwife, health visitor or your GP for support.

You can also get in touch with the NHS Talking Therapies programme.

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Scar massage after caesarean birth :: Scar massage after caesarean birth :: Kingston and Richmond NHS Foundation Trust

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Patient information: how to massage your caesarean scar to break up scar tissue and improve recovery

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everything you need to know

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Effects of vaginal microbiota transfer on the neurodevelopment and microbiome of cesarean-born infants: A blinded randomized controlled trial

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The microbiomes of cesarean-born infants differ from vaginally delivered infants and are associated with increased disease risks. Vaginal microbiota t...

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"68% of women diagnosed with absolute cephalopelvic disproportion in a previous pregnancy went on to have a vaginal birth in future."

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Just when you thought the pressure on mothers couldn't be any greater, science and the media machine that interprets it have come up with a brand new Darwin-shaped stick to beat us with. According to a "simple mathematical model" published this week, the rising rate of caesarean sections could be explained by an evolutionary trend whereby the procedure itself perpetuates small pelvises in women.

Babies who would previously have died during childbirth because they were unable to fit their large heads through their mothers' narrow pelvises are now saved by caesarean sections. According to the theory, the small-pelvis genes of the mother are then passed on to the next generation, defying natural selection. Researchers predict that this will lead to an evolutionary loop requiring increasing numbers of caesareans as the generations go by.

It makes sense that dramatic and persistent changes to the way we give birth will have an impact on the way our species develops. But I find myself irked by the narrow and inaccurate slice of the evolutionary pie the study has chosen (reflective of a broader trend in how contemporary childbirth is understood).

This research is based on an assumption that, while foetuses grow larger to increase their chances of survival (as low-birth weight is associated with poor outcomes), women's bodies have somehow malfunctioned. It takes for granted that reporting of cephalopelvic disproportion is accurate and scientific, and ignores the myriad other factors at work. None of these assumptions stand up.

Despite this, the paper has been widely reported, becoming another weapon in the polarising media fight involving women's bodies and the medical establishment.

With predictable regularity, every time the caesarean rate is mentioned, women are blamed: women, with their irrational desires to give birth when they are too old, too fat, or their bodies are otherwise addled by the irresponsible things they've done to them prior to becoming human incubators.

In the current, divisive climate around women's choices in childbirth, it's easy to take the step forwards from conjecture to another layer of guilt and pressure on women to do better or risk the future of the human species. One article reporting on the study used the phrase "too posh to push".

But are women's bodies really malfunctioning with increasing regularity, and is that why the caesarean section rate is rising? The short answer is no. As the paper itself admits, there's no standardised way of measuring, recording or tracking suspected cases of a narrow pelvis/large head. There have been attempts to use shoe size, x-rays and scanning technology to predict the phenomenon, but these have been largely unsuccessful, demonstrating that pelvis size isn't in itself a useful predictor of a difficult birth.

Many women are told their bodies have failed to make a path for the babies they have grown. But in this study, 68% of women diagnosed with absolute cephalopelvic disproportion in a previous pregnancy went on to have a vaginal birth in future. True cephalopelvic disproportion is very rare, reserved in the main for women with pelvic damage and those (largely in the developing world) suffering from malnutrition. The paper is based on a measurement that's often little better than a whim created by an obstetric culture that was (and sometimes still is) steeped in the idea that women's bodies don't work, and which has the language to prove it: "incompetent cervix", "failure to progress", "lack of maternal effort".

But caesarean rates have escalated way beyond what can be explained by cephalopelvic disproportion, even taking at face value the specious figures (which estimate instances of CPD were 30 in 1,000 births in the 1960s and are 36 in 1,000 births today).

Childbirth practices have altered almost beyond recognition in the past 100 years. Birth has been brought into hospital after being largely a community-based event. Medical intervention and expertise have increased, bringing with them many life-saving interventions and huge progress but also some side-effects. Low-birth weight infants are far more likely to survive. Women have fewer children each but more multiple births. And maternal nutrition is far better, at least in the developed world. The paper is seemingly blind to these and many other interrelated factors.

The theory is also strangely quiet on the dramatic impact of place of birth on intervention rates. The 2011 Birthplace in England study, which looked at about 60,000 births, highlighted that - far beyond the fractional impacts of rapid evolution - our maternity system and obstetric practice lead to unnecessary interventions.

More than 40% of low-risk women who give birth in hospital (where the vast majority of women give birth in the UK) face a caesarean or instrumental birth, but for a woman with the same risk-profile who plans to give birth at home, that risk drops to 10%. Caesarean rates are often driven by factors outside the woman - not by a failure of her skeleton.

I regularly fight for women who want or need caesareans to have access to them, and know that a focus on caesarean rates can impact negatively on the women who need them most. But for most women, keen to have as uncomplicated a birth as possible, current practice often leads to a caesarean that they may not have needed yet will probably be reported as a failure within their bodies rather than the system.

This is not good enough. The issue is not whether caesareans or vaginal birth are safer, better, or more likely to lead to an uncomplicated future for humanity, but simply that women matter during childbirth. Many faced intervention they didn't need and wanted to avoid, while others struggled to get a caesarean that would make birth feel safe for them.

Skewed research of this kind adds little to our knowledge base but feeds the damaging media appetite for woman-blaming and dichotomised depictions of childbirth that are a weighty burden for new mothers to bear.
Topics

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Caesarean sections are rising - but don't blame mothers | Rebecca Schiller

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Just when you thought the pressure on mothers couldn't be any greater, science and the media machine that interprets it have come up with a brand new Darwin-shaped stick to beat us with. According to a "simple mathematical model" published this week, the rising rate of caesarean sections could be explained by an evolutionary trend whereby the procedure itself perpetuates small pelvises in women.

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for when you're sick of hearing negative ones!

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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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NHS advice

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Advice about stitches, piles, bleeding and other physical changes after birth, plus tips to help you make a healthy recovery.
If you've had a caesarean, see recovering from a caesarean.

Stitches

If you've had stitches after tearing or an episiotomy (cut), bathe them every day to help prevent infection. Have a bath or shower with plain warm water then carefully pat yourself dry.

If your stitches are sore or uncomfortable, tell your midwife.

Painkillers can help. If you're breastfeeding, check with your pharmacist, midwife or GP before you buy over-the-counter painkillers.

Stitches usually dissolve by the time the cut or tear has healed, but sometimes they have to be taken out.

Going to the toilet

At first, the thought of peeing can be a bit frightening - because of the soreness. Drinking lots of water dilutes your urine, which may make it sting less.

Tell your midwife if:

you're finding it really difficult to pee

you feel very sore

you notice an unpleasant smell

You probably won't have a poo for a few days after the birth, but it's important not to let yourself get constipated.

Eat plenty of fresh fruit, vegetables, salad, wholegrain cereals and wholemeal bread, and drink plenty of water.

If you've had stitches, it's very unlikely you'll break them, or open up the cut or tear again.

It might feel better if you hold a pad of clean tissue over the stitches when pooing. Try not to strain.

Talk to your midwife or GP if you have constipation that won't go away. A gentle laxative may help.

Also tell your midwife or GP if poo is leaking or you're pooing when you don't mean to.

Bladder control

After having a baby, it's quite common to leak a bit of pee if you laugh, cough or move suddenly.

Pelvic floor exercises can help with this but tell your GP at your postnatal check if they aren't. They may refer you to a physiotherapist.

Piles

Piles are very common after birth but usually disappear within a few days.

Eat plenty of fresh fruit, vegetables, salad, wholegrain cereals and wholemeal bread, and drink plenty of water. This should make pooing easier and less painful.

Try not to push or strain - this will make the piles worse.

Let your midwife know if you feel very uncomfortable. They can give you a cream to soothe the piles.

Bleeding after birth (lochia)

You'll bleed from your vagina after the birth. It will be quite heavy at first, and you'll need super-absorbent sanitary towels. Change them regularly, washing your hands before and afterwards.

It isn't a good idea to use tampons until after your 6-week postnatal check because they could increase your chance of getting an infection.

See when you can start using tampons after birth.

You may notice the bleeding is redder and heavier when you breastfeed. This happens because breastfeeding makes your womb contract. You may also feel cramps similar to period pains.

The bleeding will carry on for a few weeks. It will gradually turn a brownish colour and decrease until it finally stops.

If you're losing blood in large clots, tell your midwife. You may need some treatment.

When will my periods start again after pregnancy?

It's hard to be exact about when your periods will start again, as everyone is different.

If you bottle feed your baby, or combine bottle feeding with breastfeeding, your first period could start as soon as 5 to 6 weeks after you give birth.

If you fully breastfeed (including at night) without any bottle feeding, your periods may not start again until you start to reduce breastfeeding.

How soon after giving birth can I get pregnant?

You can get pregnant as little as 3 weeks after the birth of your baby, even if you're breastfeeding and your periods have not started again yet.

Find out more about when you can use contraception after having a baby.

How soon can I use tampons after giving birth?

You should not use tampons until you've had your 6-week postnatal check. This is because you'll still have a wound where the placenta joined with the wall of your womb, and you may also have tears or cuts in or around your vagina.

Using internal sanitary products like tampons and menstrual cups before this wound has healed could increase your chance of getting an infection.

Use maternity pads or sanitary towels during this time while your body is still healing.

Breasts

To begin with, your breasts will produce a yellowish liquid called colostrum for your baby.

On the third or fourth day, they may feel tight and tender as they start to produce milk.

Wearing a supportive nursing bra may help. Speak to your midwife if you're very uncomfortable.

Read more about breastfeeding in the first few days.

Tummy

After delivery, your tummy will probably still be a lot bigger than before pregnancy. This is partly because your muscles have stretched.

If you eat a balanced diet and get some exercise, your shape should gradually return.

Breastfeeding helps because it makes your womb contract. You may feel quite painful period-like cramps while you're feeding.

You could also try these gentle postnatal tummy exercises.

Is it something serious?

Tell your midwife, health visitor or GP straight away if you get any of these symptoms.

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Advice about stitches, piles, bleeding and other physical changes after birth, plus tips to help you make a healthy recovery. If you've had a caesarean, see recovering from a caesarean. If you've had stitches after tearing or an episiotomy (cut), bathe them every day to help prevent infection.

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What is vitamin K?

Vitamin K plays an important part in making our blood clot. If blood can't clot properly, uncontrolled bleeding can happen.

Why does my baby need vitamin K?

All babies are born with low levels of vitamin K. Although these vitamin K stores get used up quickly in the first few days of a baby's life, (NHS 2008) there is usually enough to stop bleeding. However, a very small number of newborn babies, about one in 10,000 babies, have vitamin K deficiency bleeding (VKDB) (NHS 2008). These babies don't have enough vitamin K to make their blood clot.

If your baby has a deficiency of vitamin K, he may spontaneously bruise or bleed. This can happen within the first 12 weeks of birth. Early warning signs are bleeding from the nose or mouth, or bleeding from the umbilical stump or bottom (NICE 2006).

However, some babies who suffer from VKDB do not have these visible early bleeds. Instead, the first bleed may be a serious one into his brain or gut. These bleeds are internal, so it is unlikely that you will be able to tell if your baby has had one. Such bleeds can be life-threatening.

For this reason, doctors recommend that all babies receive vitamin K after birth.

There are three categories of VKBD:

Early VKDB: bleeding in the first 24 hours after birth

Classic VKDB: bleeding in the first week of life

Late VKDB: bleeding when your baby is two weeks to 12 weeks old

(Medline 2012, Tidy 2014)
Late VKDB is very rare, but, it is the most worrying category, as it is the most likely to cause fatalities. If your baby has late VKDB, he is more likely to have internal bleeding, which is harder to detect and can be very serious.
In more than half late-onset cases, babies have a brain haemorrhage. Sadly, a fifth of these babies die (NICE 2006).

Some babies with VKDB do not have any risk factors. But in most cases, VKDB affects breastfed babies who:

were born before 37 weeks of pregnancy

were born by forceps, ventouse or caesarean section

have been bruised during birth

had breathing difficulties at birth

have liver problems or were poorly at birth

whose mums have taken drugs during pregnancy, either for epilepsy, to prevent clots, or for tuberculosis
(NCT 2010, Pereira 2003, NICE 2006)

Breastfed babies with these factors are more vulnerable to VKDB than bottled-fed babies because formula milk is supplemented with vitamin K at higher levels than those naturally found in breastmilk. Eating a diet rich in vitamin K foods will have little or no effect on how much vitamin K there is in your milk (Booth 2008, NCT 2010).
This does not mean that you have to think about formula-feeding instead. Doctors advise that all babies have vitamin K at birth, and this includes formula-fed babies.

Your breastfed baby will get the extra protection he needs from one or more doses of vitamin K. This means that he will get all the benefits of breastfeeding as well as protection from VKDB. Breastfeeding soon after birth and on demand will also help to boost your baby's own vitamin K levels. Your colostrum contains more vitamin K than later breastmilk, and feeding on demand will help to maximise your baby's intake (NCT 2010).

Doctors recommend that your baby has a dose of vitamin K by an injection. This is because it is the most effective and efficient way of protecting babies from VKDB (Sutor 2003). One injection is all your baby needs, and it gives him immediate cover (Busfield et al 2007, NICE 2006). If your baby has risk factors for VKDB, an injection of vitamin K will also be more easily absorbed than oral drops (Pereira 2003).

As with any injection, it can be sore and leave a little bruise, but it'll only take a few seconds.

If you decide to opt for the vitamin K drops instead, you need to make sure that your baby gets all of the doses. Studies on giving vitamin K by mouth have found that missed doses can leave babies vulnerable to late-onset VKDB (NICE 2006, Wariyar et al 2000). It can be easy to forget about the right number of doses when you are going through the first hectic weeks of being a new parent.

The number of drops your baby needs depends on whether he is breastfed or formula-fed. Your baby will need:

Three doses of vitamin K by mouth, if your baby is breastfed. Two doses are given during his first week of life, and another dose is given when he is one month old.

If your baby is bottle-fed, you can opt for two doses of vitamin K by mouth during his first week of life.
(NICE 2006, Van Winckel 2009)

Busy maternity units may sometimes miss giving your baby vitamin K drops or an injection. Make sure you or your partner check with your midwife before you leave hospital that your baby has received the correct dose of vitamin K.
What if I don't want my baby to have vitamin K?

Doctors strongly recommend that your baby is given vitamin K. Although VKDB is rare, it is very serious and can be fatal.

There is no strong evidence that vitamin K is harmful, but there is good evidence that vitamin K given by injection or by mouth can help prevent VKDB and improve blood clotting in newborns (NICE 2006, Puckett 2009). The administration of vitamin K to newborns has meant that there are now very few cases of VKDB in the UK (Tidy 2014).

It is also worth bearing in mind that not all babies who get VKDB have any of the risk factors, which could leave your baby open to risk if he does not have vitamin K. An injection of vitamin K is therefore recommended for all babies, not just the ones who are at risk of developing VKDB.

However, if you really don't want your baby to have vitamin K, you don't have to allow it. But before you decide, talk to your midwife or doctor about vitamin K. Ask their opinion and if they have any leaflets that you can read.

Whether or not you decide to give vitamin K to your baby, and how, make sure that you report any unexplained bleeding to your doctor or midwife immediately.

Last reviewed: February 2014

References

Booth S, Al Rajabi A. 2008. Determinants of vitamin K status in humans. Vitamins and hormones. 78:1-22 www.ncbi.nlm.nih.gov [Accessed February 2014]

Busfield A, McNinch A, Tripp J. 2007. Neonatal vitamin K prophylaxis in Great Britain and Ireland: the impact of perceived risk and product licensing on effectiveness. Archives of Disease in Childhood 92:754-8

NCT 2010. Vitamin K. www.nct.org.uk [pdf file, accessed January 2014]

NHS. 2008. Vitamin K and vitamin KJ deficiency bleeding in the newborn. www.royalfree.nhs.uk [pdf file, accessed January 2014]

NICE. 2006. Routine postnatal care of women and their babies. National Institute of Health and Clinical Excellence. www.nice.org.uk [pdf file, accessed January 2014]

Fear NT, Roman E, Ansell P, et al. 2003. Vitamin K and childhood cancer: a report from the United Kingdom Childhood Cancer Study. British Journal of Cancer 89(7):1228-31

Pereira S, Shearer M et al. 2003. Intestinal absorption of mixed micellar phylloquinone (vitamin K) is unreliable in infants with conjugated hyperbilirubinaemia: implications for oral prophylaxis of vitamin K deficiency bleeding. Archives of Disease in Childhood: Fetal and Neonatal Edition. 88(2):113-8

Puckett RM and Offringa M. 2009. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database of Systematic Reviews Issue 4. Art. No. CD002776. onlinelibrary.wiley.com [Accessed January 2014]

Ross JA and Davies SM. 2000. Vitamin K prophylaxis and childhood cancer. Med Pediatr Oncol 34:434-7

Sutor A. 2003. New aspects of vitamin K prophylaxis. Seminars in thrombosis and nemostasis. 29(4):373-6

Tidy C. 2014. Vitamin K deficiency bleeding. Patient.co.uk www.patient.co.uk [Accessed February 2014]

Van Winckel M, De Bruyne R et al. 2009. Vitamin K: an update for the paediatrician. European Journal of Paediatricians. 168(2):127-34

Wariyar U, Hilton S, Pagan J, et al. 2000. Six years' experience of prophylactic oral vitamin K. Archives of Disease in Childhood Fetal & Neonatal Edition 82(1):F64-8

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Vitamin K plays an important part in making our blood clot. If blood can't clot properly, uncontrolled bleeding can happen. All babies are born with low levels of vitamin K. Although these vitamin K stores get used up quickly in the first few days of a baby's life, (NHS 2008) there is usually enough to stop bleeding.