Your home birth
Preparing the body for birth.
From birth and pain management techniques to the physiological details of birth.
Birth techniques and pain management
There is no right or wrong way to give birth, and there is certainly no best or worst way either. If you are planning to have your baby at home, and/or looking to avoid unnecessary medications or interventions, then you may be seeking suggestions to help facilitate a natural labour and birth. This page outlines some popular birth techniques and pain management ideas to assist you in a natural and empowering birth.
Water birth is one of the most commonly recognised methods of birthing. Most hospitals have a pool. Pool hire is one of the primary functions of regional home birth groups in Aotearoa. Waterbirths require little technical skill or practice which makes them suitable for almost any birthing woman. The temperature and sensation of the water helps reduce pressure and pain in the birthing woman and promotes good positioning to birth baby. Water is often used as a pain management tool with or without the actual birth taking place underwater. A Cochrane review found that immersion in water significantly reduced the need for and use of epidurals, a reduction in the duration of the first stage of labour and higher level of satisfaction with the birth experience. There is also evidence that birthing underwater reduces perineal tears and the need for episiotomies. Supporters of water birth believe that the transition to the outside world is less traumatic for babies who are born in water. The idea is that the warm waters of the pool will feel like the waters of your womb to your baby. Babies born in water are often calm, and cry less than babies born in air. Babies born in water are protected by the “dive reflex”. Your baby will instinctively close his airway, stopping him from breathing in water. The optimum temperature for giving birth in water is between 34-37 degrees celsius. It is important that the water temperature does not go above the usual body temperature as the baby cannot shed heat when inside your body. There is no evidence on the impact of lower temperatures, and some women prefer to have a cooler pool in the first stage, raising the temperature only for the actual birth.
The Alexander technique is not birth specific but it is often applied to birth because it works with the natural structure and function of the body to facilitate natural physiological processes. The key tenets are ‘Awareness, Inhibition, Direction’ which are used to facilitate natural movement in coordination with the mind. Women using Alexander technique in birth will prepare and practice throughout pregnancy so that they are prepared for birth. They will often be encouraged to birth upright and move around a lot during labour as well as using dynamic positioning to optimise birth. Techniques such as focussing on salivation (a dry mouth is a sign that there is too much adrenaline) and a whispered ‘ah’ vocalisation are part of the process to deal with pain. The Alexander technique recognises that birth is not a pathological illness but a physiological norm and therefore the body is supported to give birth as it is designed to do. In an ‘Alexander’ birth a woman ‘gets out of the way of her own body’ so she can birth effectively and listen to her body.
Calm Birth is a commercial system of classes that prepare women and partners for birth. It is based on the philosophy that labour and birth are normal life events. The techniques used include meditation, visualisation, massage, breathing techniques and movements that support the physiological processes of birth. The calm birth philosophy acknowledges that women have been conditioned to fear birth and as such multiple techniques are used to let go of these fears. Birth partners or spouses are asked to engage in the calm birth process as well and offered tools to best support the birthing mother to birth in joy and confidence.
Hypnobirthing is a commercial system of classes pioneered by Marie Mongan that primarily uses self hypnosis to promote a natural and peaceful birth. The techniques used are deep relaxation, breathing and visualisation to help promote the release of endorphins and oxytocin, and avoid the release of adrenaline which can halt birth or make it more painful.
Bradley birthing is also known as ‘husband/partner coached birthing’. It is a system which recognises that natural birth should be supported. The protocols suggest specific diet and exercise during pregnancy to prepare for a trouble free birth. The technique focuses on the 6 needs of the labouring woman which are deep relaxation, abdominal breathing, quiet, darkness and solitude and physical comfort.
Lamaze was pioneered in the 1940’s by an obstetrician who was concerned about the brutality of obstetrics at the time which involved strapping women down and dosing them with drugs that impaired memory and recollection. His techniques used focussed breathing, movement and massage to enable women to birth without intervention. The rise of medicalised birth and particularly epidurals mean that Lamaze is no longer about an alternative method of birthing and is more complementary to a medical birth setting.
The McMoyler method is a commercial system of classes that offers strategies for a non medicated labour, but also prepare women and partners for a hospital based birth including interventions. Couples are coached through how to work with a medical team and what kind of medication or intervention they may expect during birth. The McMoyler method is primarily for those wishing to birth in a medical setting and takes a fear based approach.
Orgasmic birth is less of a specific technique and more of an acknowledgement that the system of oxytocin via the posterior pituitary/Fergusson reflex and the clitoral area can combine to make birth an orgasmic experience. This can be encouraged and facilitated by manual stimulation, kissing, deep relaxation and other techniques that promote oxytocin, or it can happen spontaneously.
Active birth is a formal recognition of what birthing humans have realised for a very long time, that active upright labouring facilitates a good birth. Modern active birth was promoted by author Janet Balaskas during the 1980s, pushing back against modern medicalised birth that was ‘actively’ managed. There is no specific ‘way’ to do active birth, it is a philosophy relating to trusting in the innate ability of the body to direct you to move, position and birth in the way that instinctively feels right for you.
Vocal Toning and other vocalisation
Vocal toning is a technique where women make an extended vowel sound as they labour. Often groups of women will tone together to support a birthing woman. There is a physiological connection between the vocal cords, the respiratory diaphragm, and the perineum, as well as the jaw and the cervix. Vocal toning enhances that relationship and helps women achieve focus and relaxation during labour. Vocalisation that are productive and beneficial are those that fall into the deeper registers. Animalistic grunts, moos, moans and low singing can all help. Women will often make these noises as a natural part of labour. Higher pitched noises should be avoided as they are associated with stress and tightening rather than the relaxation of the deeper sounds.
Practicing yoga during pregnancy can help to prepare you physically and mentally for labour. Some people find that yoga breathing practice is useful during labour and that practice can assist with the mental endurance required for coping with pain in labour. There are also specific yoga postures for use during labour.
Free birth, or unassisted birth, refers to the choice to birth without the assistance of a medically trained assistant. The reasons for free birthing are usually to have full autonomy and freedom to birth where and how a woman chooses to. Some women choose to free birth to ensure they have full privacy, quiet and lack of disturbance to ensure they are fully able to give over to the process and in doing so find birth easier and more enjoyable. They find that the choice to birth this way frees them of fear and fully enables them to utilise their intuition and inner psyche to birth naturally.
Tools and techniques to assist birth and manage pain
Acupressure is generally accepted as a professional technique undertaken by qualified practitioners. However there are a number of points that are easily located and manipulated either by a birth partner or birthing woman to help facilitate birth. Some of these points are included as part of antenatal training or can be demonstrated by a practitioner.
Having a birth partner who can use light touch massage or massage techniques to promote oxytocin and endorphins can assist with pain. Shoulder massage can be good to help relax and allow you to untense your body. Back massage can feel sooth pain and help you to feel loved and relaxed during early labour, especially during rest periods. The application of firm pressure on the lower back during strong contractions in more advanced labour can counteract some of the pain and pressure of the contraction. Foot massage can hit some pressure points that affect other part of the body and also keep up circulation during labour. Holding or rubbing your hands can be a good way for your support person/people to stay physically connected with you whilst still allowing your some space during intense periods. Holding you up, and/or being available to physically press and push against is also useful touch during labour. It is worthwhile practicing some different assisted birth and labour positions before your birth to see what feels comfortable and right for you.
A variety of homeopathic remedies can be used during and for recovery and well being post labour. Many midwives carry some remedies and an experienced homeopath can advise on remedies to have on hand during your birth.
This is originally a South American scarf that is used as clothing or baby wearing. However a rebozo can also be used during labour and birth for various positioning techniques that can assist the birthing woman in finding a comfortable or suitable position to birth in or offer relief from discomfort.
A swiss ball can help you stay upright in labour, with your knees below your hips. This pose uses gravity to encourage the pelvis to open. The sitting position encourages your uterus to lift up allowing the baby’s head to push down on the cervix effectively, thus dilating faster. Sitting upright can also help with backache and relieve labour pain
A birthing chair or stool will help to keep you in an upright position during labour and provide support to stay upright. There are many instances of historical birthing chairs and stools, with a large variety available now as well.
Many woman find the use of heat helps to elevate back and stomach pain during labour. The use of hot water bottles, wheat bags and hot towels are common ways to facilitate this. To use hot towels during labour, support people will most likely need rubber gloves to handle the towels. Using a warm towel on the perineum during pushing can also help to avoid tears.
TENS stands for transcutaneous electrical nerve stimulation. A TENS machine consists of a hand-held controller connected by two sets of fine leads to four sticky pads. These are placed on your back. The machine gives out little pulses of electrical energy that reach your skin via the leads and pads. The pulses may give you a tingling or buzzing sensation, depending on the setting. Some people find this a very effective pain relief during labour. You can often borrow or hire a TENS machine from a midwife or mothers group.
Perineal massage can reduce your chance of tearing during birth. Just rub sunflower, olive oil, vitamin E oil or coconut oil into the skin between your vagina and anus once or twice a day, starting from around 34 weeks onwards. Place your (or your partner’s) thumbs shallowly into your vagina (no more than three to four centimetres) and press the perineal floor down towards the bowel and to both sides until you feel a slight burning or stretching sensation. Maintain the pressure for about a minute before resting. The pink kit has more information on this. Rosehip oil is known to be an excellent scar repair for tears or episiotomy sites.
Similar to the use of breath and self hypnosis, you can use the power of your mind to help you to reframe and manage the pain of labour and birth. Some women find it helpful to practice various techniques during pregnancy to develop this ability to use your mind to re focus and alter your perception of the pain. A good antenatal class will provide some training and practice of these kind of techniques.
Focus your attention on any specific non-painful part of the body (hand, foot, etc.) and alter sensation in that part of the body. For example, imagine your hand warming up. This will take the mind away from focusing on the source of your pain, such as your back pain. You can also focus on something outside of yourself. Many women find a candle burning a nice focus.
Mentally separate the painful body part from the rest of the body, or imagine the body and mind as separate, with the pain distant and far from your mind. For example, imagine your painful lower back sitting on a chair across the room and tell it to stay sitting there, far away from your mind.
Reading, saying or thinking positive affirmations can help you to reframe your thinking and also provides another altered focus. Some women like to decorate their birth space with affirmations, or to practice positive affirmation during pregnancy. Please see our resources section for some affirmation ideas
This involves imagining a numbing anesthetic spreading across the painful area, or imagine a soothing and cooling ice pack being placed onto the area of pain, making the pain dissipate and disappear. Alternatively, you can imagine your brain producing massive amount of endorphins, the natural pain relieving substance of the body, and having them flow to the painful parts of your body.
Use your mind to produce altered sensations, such as heat, cold, anesthetic, in a non-painful hand, and then place the hand on the painful area. Envision transferring this pleasant, altered sensation into the painful area.
Focus your attention on a pleasant place that you could imagine going – the beach, mountains, etc. – where you feel carefree, safe and relaxed.
Silent counting is a good way to deal with painful surges. You might count breaths, count holes in an acoustic ceiling, count floor tiles, or simply conjure up mental images and count them.
Many women find that they enjoy having music play to help release some endorphins and as something alternative to focus on. Some women may use music that enables deep relaxation such as meditation music, natural sounds from nature (ocean waves are perfect as they have a very hypnotic meter).
Rocking, swaying, walking, squatting, pushing, stretching and changing position can all help with different pains in different parts of the body. Don’t be afraid to move in the way your body desires to.
Light and dark
Dark spaces help out the hormones of labour and childbirth to do their thing. A darkened space may also help you to feel more generally relaxed, less self conscious and alert and more able to give over to your instincts. Candle light is excellent for this and a great advantage of having a home birth. Conversely, very warm sunshine promotes endorphin release. Some women may find that a warm sunny day or the sun on their skin is the ideal labouring space.
Again, an advantage of being at home, is the ability to burn essential oils. A word of warning however is that often your sense of smell is heightened, or your preferences can be dramatically different during labour, so have your support people prepared to remove an offensive smell if you want them to. Clary sage is often recommended as it promotes labour. Rose and ylang ylang are very female centred oils that help connect you to your uterus.
The body during pregnancy
Pregnancy is such an transforming event, emotionally, spiritually and physically. The physical impacts are varied and individual, although the growth of baby follows a general trend. A typical pregnancy lasts for approximately 280 days, or 38-43 weeks. This time is measured from the last day of the previous menstrual cycle, and is therefore 38 weeks, 2 days after ovulation. A birth occurring from between 37 weeks to 42 weeks in duration is considered a full term baby and a baby born within these times are completely within the realms of normal. Pregnancy is generally segregated into three separate trimesters, each around 3 months long. Physiological changes occur to to provide for baby from conception, this is an amazing (and sometimes overwhelming) process. Some changes that occur during pregnancy will become a part of your physiology for a lifetime and some are more temporary. Physically, our body increases its blood sugar, lung capacity and cardiovascular capability within the first few days which can leave newly pregnant women feeling short of breath and a bit tired. Progestogen and oestrogen hormone levels rise to prepare the body for what is to come next, leading to a synchrony of changes which turns a singular body into two beings.
The first trimester, weeks 1-12
The body changes immediately from conception. Some women can feel the pregnancy from the moment of conception, for others it can be when they notice some pregnancy signs. As your baby begins to grow, your womb grows with it. The Uterus can expand up to 20 times its size during pregnancy! During the first trimester, your baby changes from a single fertilized cell (a zygote) to the embryo that implants itself in your uterine wall to a peach-sized bundle of growing limbs and body systems. Organs take shape, baby starts to move at around week eight, and hair follicles and nail beds form. Other major first-trimester milestones include the formation of muscles, the production of white blood cells to fight off germs, and the development of vocal cords. Your body in the first trimester grows an entire organ; the placenta, which provides nutrition, oxygen and blood to your baby. You may also experience an onslaught of pregnancy hormones which in turn can cause some of the common pregnancy signs listed below. Common pregnancy signs at the beginning of pregnancy include:
- Nausea – known as ‘morning sickness’, this can affect you at anytime, or all the time. The actual cause for morning sickness is undefined though research indicates that there are multiple possible causes from hormones to genetic predisposition. It typically resolves after the first trimester. Extreme nausea during pregnancy is called hyperemesis gravidarum and can require medical treatment or hospitalisation due to dehydration.
- Increased urination – the pregnancy hormone hCG, which is increases the blood flow to your pelvic area and your kidneys, (which become more efficient during pregnancy) causes increased urination.
- Fatigue – Your body’s going into full-work mode to create a life-support system for your growing baby, especially the placenta, so it is normal and common to feel a lack of energy, particularly in the first trimester.
- Mood swings – some women find themselves more emotional or sensitive than usual. Again this can be attributed to hormones in the body operating to build your baby. Take care and surround yourself with people who will understand.
- Tender or sensitive breasts – your breasts may swell, feel sensitive, tender and/or painful, this is due to the hormone influx and increased blood supply as well as your body creating new glandular tissue to provide breastmilk.
The second trimester, weeks 13-28
Many women experience a feeling of rejuvenation or become more energized at some stage during the second semester. Pregnancy weight gain picks up, and is likely to become more noticeable. The amount of healthy weight gain during a pregnancy varies. Weight gain is only partly related to the weight of the baby and growing placenta, and includes extra fluid for circulation, and the weight needed to provide nutrition for the growing fetus. The amount of weight you may gain is very individual to each person and their body. It is is the range of 5-20+ kgs. An exciting development around 20-21 weeks is feeling the movement of the baby, which is called quickening. Later in pregnancy the baby’s movement can be visible. Braxton-Hicks contractions may begin to be felt during the second trimester. This is where the uterine muscles tense or contract.
Breasts during pregnancy:
- Your nipples. In addition to achiness and tingling, your nipples may be protruding more than usual. Although they might look luscious, they may not feel it, and may be extra tender. If you are still breastfeeding another child you may experience breastfeeding aversion.
- Your areolas. Your areola, the dark area around the nipple is likely to become darker, possibly spotted, and just plain bigger, a phenomenon that will continue as the months pass. The same hormones that cause the darkening of this pigment may also cause a darkened line up your tummy, this is called linea nigra. Your areola will also be sporting Montgomery tubercles, little goose bumps (actually sweat glands) that supply lubrication to the area.
- Your breasts. You’ll also notice a complex highway of blue veins just below the skin’s surface, which carry nutrients and fluids from mother to baby.
The Third Trimester weeks 29-Birth
During the third trimester, your baby is busy developing to be born. Gaining weight in the form of fat, fully developed hearing and, near the end, mature lungs, and keen reflexes all mean baby will be ready for the outside world soon. You will continue to gain weight and may experience some discomfort as you carry baby and yourself about the place. Back and pelvic pain is unfortunately reasonably common during pregnancy, especially the third trimester. A combination of weight, awkwardness and hormones makes pregnant women vulnerable to injury as well. Water, massage and sleeping with supporting pillows can all aid aches and pains. Some aches may be resolved with an increase of magnesium intake – this includes night cramps. Your body secretes relaxin which loosens the pelvis in preparation for birthing, this will make your joints more flexible and puts you at risk of over stretching. You may also notice increased swelling and puffiness, especially around your feet at the end of the day. Some swelling is completely normal, your midwife will be able to guide you on when to be concerned. You are likely to experience more frequent and sometimes more intense Braxton Hicks contractions, this is your body practicing for birth.
Braxton Hicks contractions, also known as prodromal labour or practice contractions, or incorrectly as false labour, are sporadic uterine contractions that sometimes start around six weeks into a pregnancy. However, they are not usually felt until the second trimester or third trimester of pregnancy.
They should be infrequent, irregular, and involve only mild cramping.
Braxton Hicks contractions are a tightening of the uterine muscles for one to two minutes and are thought to be an aid to the body in its preparation for birth. Not all expectant mothers feel these contractions. They are not thought to be part of the process of effacement of the cervix.
1. Dehydration can make muscles spasm, bringing on a contraction, and is thought to be a factor in extended Braxton Hicks contractions. Adequate hydration can alleviate Braxton Hicks contractions.
2. Rhythmic breathing may alleviate the discomfort of Braxton Hicks contractions.
3. Lying down on the left side can help ease the pain of contractions.
4. A slight change in movement sometimes makes the contractions disappear.
5. A full bladder can sometimes trigger Braxton Hicks, so urination may end the contractions.
During the last weeks of pregnancy, your baby’s position changes to prepare itself for labour and birth. The baby drops down in your pelvis, and usually his or her head is facing down toward the birth canal. In the last few weeks before birth corticotrophin-releasing hormone levels climb even higher coinciding with a major spike in cortisol levels. The rise in corticotrophin-releasing hormone and cortisol is supposed to help the foetal organs mature just before labour begins. This also relates to the timing of birth, through production of a ‘late-term cortisol surge’ just prior to the onset of labour. This prenatal cortisol surge has also been linked to more attentive mothering in both animals and women, and is thought to be an adaptive response that induces an increased liking for their infant’s body odours, cementing the bond between mother and baby.
Signs that labour is near: Your baby drops deeper into the birth canal, your mucous production increases, a possible bloody show, backache, frequent urination, a sense of restlessness, nesting, loose bowels and a sense of being unable to get comfortable.
Routine pregnancy screening
A number of tests are routinely offered to pregnant women. As with any intervention in the childbearing cycle, the choice whether or not to undergo these tests, rests with the woman. Your midwife can help you understand if a specific test is appropriate or useful for you before you decide. Making the decision on whether to test is individual to each family and may depend on a number of variables. Testing can be a valuable indicator on how pregnancy is progressing, and prepare women for potential issues, but it can also increase the risk of unwanted interventions or a coerced medical birth. With each test it’s valuable to weigh up the benefits, risks and alternatives. It may also be helpful to consider your rights to informed consent.
Maternal Serum Screening – Blood test
This is one of the first tests you will be offered. Generally If you consent, you give some blood samples which are analysed for:
Rhesus factor and blood group
Your blood is tested for ABO blood group and rhesus factor negative or positive. If you are Rhesus-Negative and your baby is rhesus-positive, it is possible for your body to generate antibodies against rhesus-positive blood if there is any mixing between you and your baby’s blood. Trauma to the uterus, such as miscarriage, abortion, or bleeding in pregnancy, increase the likelihood of blood mixing. Generally there are no problems in the first pregnancy with a rhesus positive child, but antibodies can target the red blood cells of future rhesus-positive babies, causing anaemia and other problems. Treatment is suggested to prevent the formation of RH antibodies. The treatment is an injection of ‘Anti-D’, a blood product containing antibodies that neutralize any RH positive blood in your system. This injection is given within 72 hours of birth of your baby, after any bleeding in pregnancy, or after a miscarriage or a termination of pregnancy (abortion).
If you experience any bleeding from the vagina during pregnancy it is important to tell your LMC (Lead Maternity Carer) as soon as possible. For a full discussion of the issue of rhesus negative pregnancies and anti-D, see “Anti-D in Midwifery: Panacea Or Paradox?” https://www.amazon.com/Anti-D-Midwifery-Sara-Wickham-Hons/dp/0750652322
Full Blood Count
Your blood is tested to see if there is a healthy amount of Hb (haemoglobin) and iron stores in your blood. Low levels of Hb, the oxygen-carrying component of red blood cells, may mean that you are anaemic. Very low haemoglobin levels can make you feel tired and lacking in energy. There is also evidence that it can lead to premature labour. However, it is worth bearing in mind that it is natural for haemoglobin levels to drop during pregnancy due to the large increase in fluid or plasma which dilutes the haemoglobin. Your stored iron levels indicate how much iron is available for your body and your baby to create new haemoglobin. Eating foods that have plenty of iron in them, such as leafy dark green vegetables, wholemeal breads, potatoes, raisins and prunes, and lean red meat is recommended. Vitamin C helps your body absorb the iron in your diet, so it is good to eat fruit with your iron rich foods. Food with natural tannins or caffeine in them will reduce iron uptake. Eating dairy at the same time as iron rich foods will reduce absorption. Some people have troubles absorbing dietary iron or find standard iron supplementation upsetting. The full blood count also examines white blood cell levels, which can indicate the presence of infection, as well as platelets, part of the body’s clotting mechanism.
Your blood will be tested to see if the Hepatitis B virus is present. Hepatitis B is a virus that can cause inflammation of the liver. Most infected people are carriers of Hepatitis B and do not have any symptoms of illness. Mothers who have the virus or are carriers are likely to pass the infection on to their newborn baby. Babies who become infected risk dying of liver-related diseases. If you have Hepatitis B your baby will be offered a course of vaccinations that start within two hours of birth. Most babies who are vaccinated will not become infected with the Hepatitis B virus.
Rubella is a generally mild childhood illness, but can cause severe malformations or miscarriage when women contract it early in pregnancy. Women who have experienced rubella in childhood or have been vaccinated usually have life-long immunity. Checking for antibodies to rubella indicates if a woman is immune. Non-immune women are warned to avoid known cases of Rubella, and to consider the option of vaccination AFTER pregnancy. Cases of Rubella are rare in NZ.
“Between 2005 and 2010, 49 cases of rubella were notified (ranging from 13 in 2005 to 4 in 2010), of which 16 cases were laboratory confirmed. 43 cases were in children aged nine years or less (see Figure 12.1 for notifications and laboratory-confirmed cases of rubella). It is important that suspected cases be notified and laboratory confirmed so that public health control programmes can limit spread (see section 12.8).There have been no cases of CRS in New Zealand newborns reported to the New Zealand Paediatric Surveillance Unit between 1998 and 2010”
Your blood will be tested to check for the presence of syphilis. Syphilis is a rare sexually transmitted disease, but it has become more common in recent years. If your blood test reveals that you have syphilis you will be offered antibiotics in order to prevent serious health problems for you and your baby, as the infection can be transmitted from mother to baby during the birth.
Testing for HIV is now routinely offered to all pregnant women. If HIV is detected, additional care and support will be offered to minimise the chance of transferring the virus to the baby during birth and breastfeeding, as well as to manage long-term health for the mother.
Benefits: Blood testing is reasonably non-invasive and gives a good picture of overall health conditions which relate specifically to pregnancy.
Risks: There are minimal risks to blood tests.
Alternatives: Women who are confident of their health or who have ethical reasons for turning down blood tests may choose to monitor their health in other ways.
Urine testing – midstream urine test
Women may be offered a routine mid-stream urine test at their first visit to check for asymptomatic urinary infections. Women are also invited to do a dipstick urine test at each visit, which usually tests for protein and glucose, and sometimes other substances such as blood or white blood cells. Protein in the urine, alongside rising blood pressure can be an indication of the pregnancy condition called pre-eclampsia or toxaemia. Glucose in the urine may indicate high blood sugar levels associated with gestational diabetes (diabetes of pregnancy) but the dipstick test alone is not a reliable diagnostic tool.
Benefits: Urine testing is a non invasive way of keeping an eye on levels of protein and glucose. It can be a good early warning sign for concerns like gestational diabetes and pre-eclampsia.
Risks: Urine tests are low risk.
Considerations: While the testing is non-invasive, false positives or high readings can lead to elevated monitoring, obstetric referral, coerced inductions and surgical births. This testing should be accompanied by a robust discussion about options surrounding the management of these concerns to avoid medicalisation of birth where possible.
Alternatives: Women can omit these tests and monitor their health in other ways they feel more comfortable with. This may mean pre-emptive dietary and lifestyle measures to reduce the risk of gestational diabetes and pre-eclampsia.
Combined Screening, Down Syndrome and other conditions – ultrasound & blood test
This is a screening tool that combines results from an early ultrasound scan and a blood test to suggest the chances of a baby having Down syndrome or some other conditions. The results are not diagnostic: risk ratio is high, amniocentesis or chorionic villus sampling would be recommended to give a definite result. Families deciding if combined screening is right for them must weigh up not only the potential risks or benefits of the test itself (ie ultrasound exposure) but also what they will choose to do with the information that is offered as a result.
Benefits: For some people, knowing that they may be dealing with a situation out of the norm is important to them. Other families may want to consider if they continue with a pregnancy. These tests can help narrow down possible risks and likelihoods.
Risks: There is no data proving the safety of ultrasounds for developing foetuses. Blood tests are low risk.
Considerations: Knowing whether your baby has downs syndrome or other similar concerns has an ethical burden. Deciding where to proceed with test results is a discussion each family should have based on their own personal situation. Amniocentesis and chorionic villus sampling are relatively high risk, increasing both risk of miscarriage and limb deficiency. The benefits of knowing should be weighed against the risk of miscarriage or other complications. A positive result may result in coerced abortion or surgical birth.
Alternatives: Declining test and as a result accepting any outcomes.
Anatomy Scan – Ultrasound
Women are offered an ultrasound scan between 18-20 weeks to attempt to identify anatomical abnormalities, such as of the heart or kidneys. The rates of detection of abnormalities vary depending on the organ system being examined, and sometimes abnormalities are missed, or normally formed organs are reported as abnormal. Depending on the severity of the abnormality, women may be counselled to birth in a location that facilitates easy access to surgery, or even abortion. Other information that can be offered includes the location of the placenta and the estimated size of the baby. While the anatomy scan is commonly chosen by families, research is clear that routine scans do not improve outcomes, and the potential dangers of ultrasound exposure are not widely discussed.
Benefits: Knowing about potential serious defects before birth can be useful, it may also put your mind at ease if you receive a clear scan.
Risks: There is not sufficient scientific data to show that ultrasounds are safe with foetuses.
Considerations: Not all defects are shown and some perfectly healthy babies may be diagnosed with a defects in error. Ultrasounds are not the most accurate tool for gauging growth in babies, yet if a baby is measuring ‘big’ this may instigate closer monitoring and induction or coerced medical birth. Women having a home birth may want to consider the birth outcomes if their baby needs immediate treatment upon birth.
Alternatives: Declining an ultrasound, accepting the reasonably low risk of abnormality.
Second Trimester blood tests
Women are commonly offered a blood test at 28 weeks to repeat the full blood count. They may also be offered a blood test to screen for gestational (pregnancy) diabetes. These tests involve drinking a preparation high in sugar before giving blood samples. While the issue of gestational diabetes is complex, women should be aware that pregnancy hormones make them more vulnerable to blood sugar imbalance if they consume large quantities of refined carbohydrates. Screening for gestational diabetes should be offered as part of a larger discussion regarding diet and activity level to maximise health and wellbeing.
Women may be offered a final blood test at around 36 weeks if there has been a concern about haemoglobin levels in the pregnancy.
Group B strep – swab
Women may be offered a vaginal/perineal swab to screen for Group B strep, which is a transient bacteria commonly found in women’s vaginas. It is harmless for women, but occasionally can be transferred to babies during the birth process and can cause severe infections. Current recommendations endorse giving intravenous antibiotics in labour to women with factors that increase the rates of infection, such as labour before 37 weeks or the water bag broken longer than 18 hours. According to these recommendations, it is not essential to know if the woman is in fact a carrier of Strep B. However, some women find their decision-making easier if they know their Strep B status.
Benefits: Reduces risk of Strep B transfer to newborns
Risks: A positive swab puts women at risk of an induction or hospitalisation during birth as well as a course of antibiotics.
Considerations: Strep B is a transient and normal colonisation of bacteria, the damage a course of antibiotics does to the microflora of mother and child may not be a suitable trade-off for some women, considering the minimal benefits shown by intrapartum antibiotics.
Alternatives: Declining a Strep B swab and using alternative treatments to reduce group strep be colonisation. This could include probiotics, vaginal Ph management and boosting the immune system.
Cochrane review – intrapartum-antibiotics-for-known-maternal-group-b-streptococcal-colonization
There are a range of other non routine tests that are available to pregnant women that may be considered.
Chlamydia – vaginal swab
While Chlamydia screening is not offered routinely by midwives in New Zealand, Chlamydia is the most common sexually transmitted infection in New Zealand. Treatment is by a single dose of antibiotics. Babies can become infected with chlamydia during the birth process, causing eye infections and other problems. Ask your midwife if you would like to be screened for chlamydia- it involves taking a vaginal swab.
Benefits: Screening for Chlamydia is a low risk test that can prevent infections in baby.
Risks: There are few risks to a swab, however a swab may introduce other microbiota to the vaginal area and cause discomfort. The swab is lower vaginal however, so no speculum is required.
Considerations: A negative test simply means there is no active infection therefore it is not a guarantee that Chlamydia will not be present later on in the pregnancy or at birth. Some women will not be comfortable with antibiotic treatment.
Alternatives: You can decline a swab and ask for a urine test instead if vaginal swabs concern you. You may choose to decline antibiotics and seek alternative treatment.
Amniocentesis & Chorionic Villus sampling
These tests are only suggested if a less invasive test has indicated a specific risk. These tests are much more invasive and involve taking samples of amniotic fluid and placenta to check for genetic issues. Both of these tests come with a risk of miscarriage and therefore come with an ethical burden.
Ultrasounds are commonplace, and are nowadays used in most pregnancies to date the pregnancy, check for gender, do a nuchal fold and nasal bone scan (to check for risk of chromosomal disorders), to check overall anatomy and as a rough guide on size later on in pregnancy. The studies supporting the use of ultrasound are not clear on whether ultrasounds are safe, and in many cases, increased surveillance of the foetus does not improve outcomes, though they can increase risk of intervention or induction. There is very little data to support the safety of ultrasounds, even though they are routinely used. Late scans are often inaccurate in gauging size by up to a kilo or more which increases the risk of early inductions or surgical birth unnecessarily. Maternal Screening is a matter for informed consent.
There is no doubt a well nourished and healthy mother has the best chance of birthing well and on her own terms. In certain situations, diet can be used to avoid conditions developing which may require intervention. Pregnancy nutrition can often be a source of controversy. Women may be told what they must eat and what they cannot eat, and this information can come from a variety of sources. Home Birth Aotearoa believe a range of diets will adequately support the pregnant body and growing infant to term. As such we suggest women take a variety of approaches to pregnancy diet depending on what aligns with their ethos and health status.
New Zealand Ministry of health offers a list of foods to be avoided during pregnancy for safety reasons. This is because pregnant women are more susceptible to listeria infection and the consequences to your baby if listeria is contracted can be severe. While this is a comprehensive list that will help significantly reduce exposure to listeria or other food-borne illnesses, you may find this list does not reflect your personal approach to food or the list is too restrictive and difficult to adhere to. It’s worth noting this is a broad list to encompass all possible situations and risk can be managed a little more closely with some discernment. In many cases the restrictions also limit a woman’s options when it comes to nutritious food choices. For example hot chips are low risk for listeria but are not particularly healthy and can spike blood sugars, whereas a salad may have a higher listeria risk but is a much more nutritionally savvy choice.
Whatever decision you make regarding nutrition it’s invaluable to make a risk assessment based on solid information, and bear in mind any restriction is only in place for the term of the pregnancy. Some women consider the rules to be inflexible, others make exceptions or interpret the guidelines to match their knowledge and understanding of diet. While these guidelines may certainly reduce risk, there is no food that doesn’t have a risk factor if improperly prepared and stored. It may also be worth considering that the limitations vary significantly from country to country. For example, New Zealand eggs are a very low risk food source when compared with other countries where salmonella risk is high in raw eggs.
Diet to Address pregnancy issues
Common pregnancy health concerns such as gestational diabetes and pre-eclampsia may be addressed by altering diet. In fact many health professionals and nutritionists believe that our industrialised diet is one explanation for the increase of certain pregnancy health issues and birth defects.
Some diets (such as the Bradley diet) are specifically designed to address and prevent these concerns from the outset and are developed with pregnancy in mind. A diet high in refined sugars, simple carbohydrates and junk food can leave a mother susceptible to these conditions. Limiting carbohydrates, sticking to whole foods and increasing hydration can prevent these conditions or treat them very effectively. A diet high in protein and low in simple sugars or processed carbohydrates is one effective way of managing these pregnancy conditions.
Plant based pregnancy
Most guidelines suggest a balanced diet of carbohydrate, protein and fat with the implication that dairy and meat protein is essential for a healthy pregnancy. However there are a wide range of balanced diets to choose from and plant based nutrition such as vegan or vegetarian is one variation of normal. It is important to recognise that not all plant based diets are equal and special care must be taken to ensure the correct balance of macro and micro nutrients. Your lead maternity carer (LMC) will be able to assist you in monitoring your underlying health.
Women’s bodies are amazing, even with a very limited diet we can successfully grow a baby from zygote to full term. It’s worth noting very restricted diets can have health implications and it may be worth consulting with a nutrition expert if you find yourself pregnant on a restrictive diet.
Pregnancy Nausea and Emesis
Women experiencing serious nausea and vomiting may find that despite their best efforts, they cannot maintain the ‘ideal’ diet and may fall back on foods which are not nutritionally ideal. While this is not the ideal situation it is also unproductive to take on additional stress because of this. In serious cases, eating whatever will stay down is a matter of basic survival. There is significant evidence to suggest that in some cases pregnancy nausea is caused by low magnesium levels or low B6 (pyridoxine) and taking supplementation may help prevent nausea or reduce the severity, assuming that the supplements don’t worsen the symptoms (swallowing can be a challenge).
Other theories regarding pregnancy nausea include the intake of meat or dairy and some women find eliminating one or the other may alleviate symptoms. Most women are finely attuned to what will cause them to feel ill and what they can tolerate, and should use this to manage their intake. Small meals and frequent meals are best to prevent blood sugar lows which exacerbate nausea and to maintain nutrition. For help with pregnancy hyperemesis look here.
The New Zealand Ministry of Health suggests two main supplements during pregnancy which are currently funded and available via your midwife or LMC. These are iodine and folic acid.
Iodine is suggested because New Zealand soils are low in this mineral and as a result it is a common deficiency. This is particularly relevant to pregnant women as it can affect the development and growth of your baby. Iodine can be naturally found in sea vegetables and certain salts. Folic acid is recommended because it has been shown to reduce instance of midline defects such as Spina Bifida, it is slightly more controversial as it is prescribed in doses which are tentatively linked to midline deformities such as a tongue ties. It has also shown to be less effective in people with MTHFR (methylenetetrahydrofolate reductase) mutations. The natural form of folic acid, folate is an alternative to folic acid and can be found in a variety of foods such as ground linseed, black eyed peas, lentils, lettuce, avocados and raw spinach.
Other supplements you may want to consider:
Vitamin D – recent study indicates that due to our indoor lifestyle, SunSmart message and processed diet people are becoming low in Vitamin D, which can cause rickets and immune issues. Additional supplementation may be a good idea.
Magnesium – magnesium is used in large amounts by the body and a shortage in magnesium is implicated in cramping, nausea, pre-eclampsia, insomnia and tiredness. Magnesium (in citrate form is best) is a good ‘catch all’ supplement to take if indicated. Women having trouble swallowing may find epsom salts baths and soaks useful.
Probiotics – Probiotics taken during pregnancy are shown to reduce incidence of allergy and asthma. They also help promote good gut health which is a key component of the bacterial exchange that occurs during birth.
Iron – Pregnant women often test low for iron which is normal given that their circulating blood levels increase significantly during pregnancy. Iron supplements may be suggested by your LMC if levels drop because they may have concerns about haemorrhage during birth.
Some women may find that standard iron supplements cause nausea and constipation. There are alternatives such as nettle tea, liquid herbal iron supplements and products like spatone. Home Birth Aotearoa believe that supplementation is not necessarily an essential part of pregnancy but given our modern diet and environment, taking additional nutrients may be advisable and should be considered on the basis of your personal health, family history and nutrition needs. Information from the Ministry of Health:
Birth is a process that is mediated by hormones, the same hormones that facilitate bonding, love, and orgasm are the hormones that let women birth well. They work in a synchrony to complement each other and guide the physical process of pregnancy, labour and birth and afterwards, breastfeeding. These same hormones that are so beneficial to mothers and the process of birth are beneficial for babies too. Labour is good for babies.
“Giving birth in ecstasy: this is our birthright and our body’s intent. Mother Nature, in her wisdom, prescribes birthing hormones that take us outside our usual state so that we can be transformed on every level as we enter motherhood. This exquisite hormonal orchestration unfolds optimally when birth is undisturbed, enhancing safety for both mother and baby. Science is also increasingly discovering what we realize as mothers- that our way of birth affects us life-long, mother and child, and that an ecstatic birth, a birth that takes us beyond our Self, is the gift of a lifetime.”
—Sarah J Buckley, Ecstatic Birth 2002
The best way to support birth and keep our mothers and babies safe is to protect the hormonal systems that mediate labour. We need protected birth spaces to promote birth as it should be. Sarah Buckley describes the hormones of birth as an ecstatic cocktail prescribed by nature to aid birthing mothers. Dim lighting, a quiet and private space, warmth and a feeling of unhurriedness allow these hormones to work in the best possible way.
”The right environment in birth is exactly the same as the environment in which to make love”.
—Sheila Kitzinger, Birth reborn (Michel Odent) 2005
We need to recognise that modern developments in pain relief and birth intervention, intervene in these processes. Synthetic oxytocin blocks natural oxytocin, opiates block endorphins and a modern medical birth setting disrupts the natural flow of hormones. An ‘augmented birth’ is not necessarily a better birth. But do these hormones really matter? Given that medical birth can occur without these hormones do we need to bother ourselves with facilitating physiological birth?
“We do not know, however, what the long-term consequences of interference with the oxytocin system may be for mothers and babies, and for their ongoing relationship.”
—Sarah Buckley, Healing Birth, Healing the Earth. 2005
To know this we need to know the function of these hormones through birth and beyond. Given these hormones are integral to bonding, love and empathy does depriving birthing women of these hormones dictate the path of human development?
“Until recently a woman could not have had a baby without releasing a complex cocktail of ‘love hormones’. In many societies today, most women give birth without relying on the release of such a flow of hormones. Some give birth via caesarean section, while others use drugs that not only block the release of these natural substances, but do not have their beneficial behavioural effects. ‘This unprecedented situation must be considered in terms of civilization”
—Michel Odent, Birth and Breastfeeding
Progesterone – The Protector
Progesterone is one of the primary hormones during pregnancy, and it’s role is to protect the developing baby. It is produced by the ovaries, adrenal glands and placenta. Progesterone is responsible for developing breast tissue and alveoli responsible for lactation as well as suppressing uterine contractions which would result in pre-term labour. It also protects the placenta and baby from being attacked by the mother’s immune system. Progesterone drops away at the onset of labour which causes the protective mucous plug to be released and the suppression of uterine surges cease. This allows the effects of oestrogen to take over.
Oestrogen – The Builder
Oestrogen is responsible for building the placenta and baby in the womb, as pregnancy progresses oestrogen levels increase as the lungs, adrenal glands, kidneys and liver develop in the baby. Oestrogen also closely regulates progesterone levels. Oestrogen increases the number of uterine oxytocin receptors in late pregnancy with these levels rising at about 34 weeks. This paves the way for labour to begin and the uterus to begin contracting.
Relaxin – The Relaxer
Relaxin is a hormone excreted primarily by the ovaries and in pregnant woman, from the placenta. As indicated by its name it helps to relax the pelvic ligaments and ripen the cervix by breaking down the collagen. It is released throughout pregnancy. Relaxin levels are high in the early stages of pregnancy to aid in implantation and prevent premature labour. It also peaks in the last trimester to prepare the body for birthing.
Prolactin – The Mother
Prolactin is called ‘the mothering hormone’ because it promotes maternal instinct, including the ‘mother bear’ response when there is a perceived threat. Interestingly prolactin levels as they increase in late pregnancy, also affect people in close proximity with the pregnant mother. This can mean that fathers and partners can also get a dose of ‘mothering instinct’ Anthropologists, Carsten Schradin and Gustl Anzenberger, describe prolactin as “the hormone of parenthood”. Prolactin has also been blamed for the nesting instinct that kicks in close to labour and the selflessness a mother gets when her baby is born which allows her to put her baby’s needs first. Primarily though, prolactin is the major hormone of milk synthesis and breastfeeding with levels rising during labour and peaking at birth when the placenta is released, levels remain high while breastfeeding continues. Prolactin can inhibit libido. Beta-endorphin facilitates the release of prolactin during labour, which prepares the mother’s breasts for lactation and also aids in the final stages of lung maturation for the baby.
Oxytocin – The Lover
The definition of Oxytocin is ‘quick birth’ and it is the hormone responsible for love, orgasm, bonding and the physical process of birthing. Birth surges known as ‘fetal ejection reflex’ are mediated by oxytocin which initiates contractions. The surges or contractions that occur during birth, while more powerful are not dissimilar to the sensations during orgasm and are both managed by oxytocin. Oxytocin can be released during a passionate kiss, physical touch, a warm smile, during sex and even when eating a delicious meal. Even better, during birth the release of oxytocin is self perpetuating via a positive feedback system known as the Ferguson reflex and as oxytocin pulses through the body at regular intervals, the uterus contracts and the cervix dilates and the mother is filled with love. However, oxytocin is sensitive to anxiety, stress and sense of observation. It will disappear quickly in the wrong environment which is why it is also called the ‘shy’ hormone. The high levels of oxytocin in both mother and baby at the time of birth promote affection, attachment and a desire in the mother to protect and guard the baby. Oxytocin, essentially, is love. The high levels of oxytocin post birth also facilitate the let-down reflex promoting breastfeeding success. Latching baby early can help facilitate an oxytocin ‘hit’ that allows the placenta to be birthed naturally, it constricts the vessels and shrinks the uterus, sometimes very powerfully causing afterpains. Oxytocin not only passes from mother to baby during birth, but also via breastmilk and so a mother is able to provide baby with oxytocin that will help set them up for a healthy bond of affection.
“The human body constantly adjusts to cues from its surrounding environment and the way we interpret our environment is through our senses. What we see, hear, taste, touch and smell triggers off a cascade of brain chemicals that control every body state and the major contributor to all this activity is oxytocin”
—Maralyn Fourer, Birth territory and Midwifery Guardianship
Synthetic oxytocin, also known as Syntocinon or Pitocin is often used to ‘augment’ labour. But because it does not cross the blood brain barrier it not only cannot facilitate bonding but it also blocks natural oxytocin production. High levels of synthetic oxytocin can desensitise the baby to mothers own natural oxytocin production. Synthetic oxytocin is administered in very high doses without the natural pulsation or the Ferguson reflex, which means that labour can be painful and overwhelming.
Endorphins – The Ecstatic
Endorphins (beta endorphins) are natural opiate like substances that mediate pain and give us a feeling of intense euphoria if they reach high enough levels. People often talk about the ‘runners high’ and endorphins in labour fulfil the same function. Endorphins have a cumulative effect and if promoted they build throughout labour to offer relief as it is needed. Endorphins are triggered by pain but also by light touch massage, intimacy, privacy and a safe comfortable environment. Endorphins are blocked by catecholamines and drugs that interfere with endorphin production. Endorphins also mediate oxytocin levels which can slow contractions and pace labour so that it is more manageable. Latest research shows that endorphins also transfer via the placenta into the baby and assist them to cope with birth by mediating pain and discomfort. They also facilitate the process where baby changes from oxygenation via the placenta to oxygenation via the lungs by enhancing the neurological response. Endorphins also pass through the breastmilk and account for the ‘milk drunk’ effect that breastfeeding can have on babies. Medical opiates like morphine and pethidine replicate endorphin effects but also have negative side effects which impact on baby’s health and the comfort of the mother. This can include a sense of detachment, nausea, skin crawling in mother and lethargy, and low apgar scores in baby. They also block natural endorphins and upset the balance of hormones in the body which can increase pain later on and reduce the chances of effective bonding. It has been suggested that low endorphin levels during labour can impact maternal mental health in the long term.
Catecholamines – The survivors
Catecholamines (adrenaline and noradrenaline) are the stress hormones that cause our body to go into high alert, which is not an ideal state to give birth. However they do have a role in labour later on, but if they are released too soon then it can slow or halt labour altogether, this is because catecholamines block and inhibit oxytocin. In fact, an adrenaline surge early in labour can stop contractions altogether and close the cervix. This is why stressed or fearful women may have a halted or protracted labour. However later in labour during transition adrenaline can be useful to support the very final stages where the baby is birthed. The effects of adrenaline and noradrenaline during transition can leave a birthing women feeling nauseas, dry mouthed, shaky with dilated pupils a palpable heartbeat. That burst of energy can be what a woman needs to get through the final moments of birth.
Melatonin – In darkness
Melatonin is the hormone responsible for inducing sleep, it is promoted by quiet, dark private spaces and often peaks in the early hours of the morning. Melatonin is significant when it comes to labour and birth as it works synergistically with oxytocin and increases the depth and effectiveness of birth surges. Bright lights, observation, monitoring and anxiety all inhibit the production of melatonin.
Many of the hormones from birth including oxytocin, prolactin and endorphins are essential to initiate breastfeeding. Home Birth Aotearoa strongly believes that a natural birth without intervention sets women and infants up for the optimal breastfeeding experience. Other hormones that are significant to a successful breastfeeding relationship are insulin, cortisol, thyroid and parathyroid hormones and human growth hormone. These hormones if in an imbalance can obstruct optimal breastfeeding. Conditions such as hypothyroid, polycystic ovary syndrome and diabetes can all impact on successful lactation.
One reason people choose homebirth is because they can avoid being contaminated by the microbiota of ill people and exposure to hospital super bugs. The flora that your baby receives upon birth will be key to their lifelong health. Protecting your baby’s ‘microbiome’ is one good reason for considering home birth.
We are the hosts to many microscopic organisms; bacteria, fungi, parasites and even tiny crustaceans, who make up an entire invisible world within and upon us: the microbiome. The microbiome is crucial to our health; it functions like a hidden organ of the body. Our microbiome is unique to us, mine differs from yours. Within our bodies, our microbiome even differ depending on which part of the body we are looking at, so there are different combinations of species that live in our gut compared to our skin, in our armpits versus up our nostrils. The organisms of each microbiome are vast in number. There are more organisms living on each one of our bodies than there are human beings living on the planet earth.
Part of the reason we couldn’t and didn’t discover this world right under our noses was because we used to have to rely on capturing or culturing organisms to tell they were there. But now, with DNA and gene sequencing techniques, we don’t have to rely on growing the bugs that we host (and creating the sometimes tricky conditions for bugs to grow). These new techniques have allowed us to debunk another myth: that babies occupy a sterile world inside the uterus. There is evidence that mothers do transfer bacteria to their unborn babies, but usually these bacteria are also ones that mothers have checked out and tamed. It’s like mothers make sure the friends that come over to play with her foetus aren’t going to be psychopaths. After birth, all new bacteria that the baby is exposed to for the first time undergo a similar maternal vetting process.
Firstly, as babies emerge from the vagina, they are slathered with vaginal organisms, including lactobacillus, selected to live in the vagina over millions of years of evolutionary time. Since lactobacillus literally means milk bacteria, it’s no coincidence that lactobacillus’ preferred diet is breast milk. When we feed our babies our breast milk, we are feeding these bacteria too. Additionally, and hopefully, babies born near their mother’s anus receive heirloom species from the mother’s gut flora. In other words, mum’s poop is the optimal starter for the baby gut microbiome. Breast milk, lactobacillus, and heirloom gut species together help grow the right microbiome; one that the mother’s immune system is already accustomed to developing and defending. It is, one investigator stated, as if “mothers are recruiting another life form to babysit their babies” (L, 2012 Sep;22(9):Epub 2012 Apr 18.).
Good bacteria are essential to our health, in ways we are just discovering. These bacteria supply us with genetic capabilities we don’t have, providing us with essential nutrients and substances we can’t otherwise obtain. For example, we get Vitamin K almost exclusively from our gut bacteria. There is evidence that babies born by caesarean section, or babies fed infant formula, have a different microbiome than babies born vaginally and exclusively breast fed. This difference can last for the rest of their lives. Because of this some researchers, including Dr Rob Knight of the University of Colorado, are studying the effects of inoculating caesarean section babies with maternal vaginal flora. Some mothers have even suggested taking matters into their own hands, so to speak, to ensure that their babies are colonised in the way nature intended.
Caesarean Sections and the Microbiome
Delayed cord clamping and skin to skin add to the picture of ensuring a healthy microbiome. Keeping the cord attached to baby means that baby stays close to mum, and not exposed to the bacteria of others. These optimal practices have other benefits of their own, of course, and they each probably have benefits we have yet to discover.
Completing the picture is birthing at home. Home is, after all, most likely to be where your microbiome is most comfortable. Hospitals are often places where bacteria have learned to be resistant to antibiotics, in fact, nosocomial or hospital acquired infections are a major source of morbidity and mortality. As we discover more about the organisms that keep us healthy we shouldn’t be surprised to also learn that creating the conditions for ensuring an optimal microbiome may include birthing at home. Interesting article on this topic here
The Microbiome was written by Alison Barrett BSc, MD, FRCS(C), FRANZCOG. Dr. Alison Barrett has worked as a specialist obstetrician and gynaecologist for many years in both New Zealand and in Canada. She was the Chief of Obstetrics and Gynaecology in a rural hospital in Ontario, and an assistant professor in the Northern Ontario School of Medicine. She is currently working as a consultant obstetrician and gynaecologist in Hamilton New Zealand, where she is a RANZCOG training supervisor for junior doctors. Prior to entering medical school Dr Barrett studied ecology and biological sciences, and these two fields continue to inform her clinical work. She has served on many committees addressing maternal and infant health issues including the National Breastfeeding Advisory Committee for the New Zealand Ministry of Health and the Infant Feeding Advisory Group for Health Canada. She is a member of the Professional Advisory Group of La Leche League New Zealand.
Gentle caesarean when intervention is necessary
One of Home Birth Aotearoa’s primary goals is to support women to have the birth of their choosing. Sometimes, despite all best efforts and robust conversations about the benefits and risks of a given situation, transfer to hospital or a caesarean section may be inevitable. This guide will help you navigate this process with the best tools at hand to make your birth an empowered one. About one in three babies in New Zealand are now born by caesarean section. Some of these births are planned and others will happen as an emergency procedure. Caesarean section is now a common experience for many families.
While homebirth families experience lower rates of caesarean section than the rest of the population, there are still some times when this intervention is inevitable. Although caesarean section is practically a routine way of giving birth today it is still a surgical procedure. Yet there is no reason birthing inside the operating room has to automatically preclude the creation of a humane, kind, affirming and celebratory life event. Because we’ve lagged behind in recognizing this need to humanize surgical birth, caesarean sections are often unnecessarily traumatic for both mother and baby, and sometimes other family members. It may surprise you that even hospital staff are vicariously traumatised. Some of the negative effects of caesarean section are unavoidable, and some of the negative physiological and psychological effects are yet to be discovered. Even still, with what we know now, we could do better in improving the experiences of mothers who meet their babies for the first time in the operating room.
Ten top tips to humanize your caesarean section:
Be awake, if possible
Except in the most pressing of emergencies, most caesarean sections can take place safely under regional rather than general anaesthetic. Although daunting to consider, being awake offers many advantages to you and your baby. Most hospitals will allow one support person to stay with you if you have a spinal or epidural anaesthetic, in addition to your own midwife. Your midwife, advocating for you, can help you get the best caesarean experience possible, so make your wishes known to her. It can pay to think a little about what is important to you, and the following steps can help.
Tell the surgical team if you want to see your baby emerging.
The team often puts up a drape near your shoulders to separate the spaces between the surgical side and the anaesthetic side of things. They may think you or your support person will be squeamish, but that’s largely a judgement call they are making and a relic of days gone by when all caesarean sections were done under general anaesthetic. Seeing your baby emerge can especially help home birthing families because one of the reasons for home birth is to make sure there aren’t important gaps in baby’s life that strangers experience instead of the family. It can be annoying, rude and disturbing when others get to see (and comment) on their newborn before they do.
Tell the surgeon you want to discover the baby’s gender in the way you had planned.
I don’t know of any family who wanted the obstetric staff to make the big announcement. If your plan was for your partner to be the one to tell, that can still happen. If you were going to discover this together yourselves, that can still happen too.
You can ask to touch your baby first.
It’s lovely if you are the first one to touch your baby. When you are anesthetised for surgery, many women describe a surreal experience until the baby is in their arms. Touching the baby is possible, over top of the drapes. The surgeon may worry about their sterile field, but as long as you don’t touch the surgeon, and stick to the baby, it’s all good.
Consider claiming the theatre space with music.
Some families bring in a special piece of music that can be played as the baby is born. It’s another way to claim the space as your own.
Most teams don’t mind photos being taken of various aspects of the birth, as long as hospital staff aren’t the focus of the pictures. Yes, there is blood, and often the best pictures are black and white shots (which, owing to the miracle of digital photography, can be done after the fact). Consider designating a photographer other than your support person so that he or she can focus on other things. Tell the photographer to take as many photos as possible. You can always delete them, but you can’t turn back the hands of time to get them if they haven’t been taken in the first place.
Bring your own baby hat
Operating theatres are often very cold and the baby may get “hatted” to prevent the loss of heat. Bring a special one to put on baby. That hat will feature in the first newborn pictures.
Delay cord clamping.
Delayed cord clamping is very important, yet some surgical teams are in a rush to clamp the cord, usually because of concerns over bleeding. The team can facilitate this by changing the surgical technique slightly. Let your obstetrician know that delayed cord clamping is important to you, and ask if the hospital has a policy to facilitate this procedure.
Skin to skin in theatre
Skin to skin is a beneficial practice, perhaps a crucial one, for newborns, particularly the caesarean born, and many hospitals have position statements that support it, at least in theory. Skin to skin helps the newborn transition to life outside the uterus, and the effects can be far reaching in terms of permanent changes to the physiology of the newborn. The mother’s body continues to be the ideal baby’s habitat after birth. We want babies to stay with their mothers to become colonized with her “safe” bacteria rather than hospital flora, and mothers in particular (rather than their partners, who are a good substitute but not quite as good as the mother). It is the mother who provides, through breast milk, an accessory immune system for the baby. Mothers need to be exposed to everything the baby is exposed to in order to help baby defend against any challenges the environment will offer. Staff often feel that mothers are not “up” to skin to skin however, you don’t need to do much other than lie there with baby snuggled on you, bare skin to bare skin. Your midwife, or one who is designated to help with the baby in the operating room, can help make skin to skin happen even as the surgeons are sewing you up.
Find out before you leave the hospital if you can VBAC, and get your hospital notes.
It might be the last thing on your mind, but the best time to ask if a vaginal birth will be possible for your next baby is now. That’s because sometimes the hospital does a bad job of documenting events at a birth, and a couple of years down the track when you really want to know, it can be difficult to chase down the truth of events that aren’t recorded.
Though many families have been down this path, it is still incredibly hard. The physical reality of caesarean section is huge. The physiological reality of caesarean section is huge. These are traumatic events, even as they can be filled with joy at the same time. Be easy on yourself. Plan for extra support and self care. When you are home, consider a re-birthing ceremony, and have a healing baby moon. This segment on a Gentle Caesarean was written by Alison Barrett BSc, MD, FRCS(C), FRANZCOG.
Dr. Alison Barrett has worked as a specialist obstetrician and gynaecologist for many years in both New Zealand and in Canada. She was the Chief of Obstetrics and Gynaecology in a rural hospital in Ontario, and an assistant professor in the Northern Ontario School of Medicine. She is currently working as a consultant obstetrician and gynaecologist in Hamilton New Zealand, where she is a RANZCOG training supervisor for junior doctors. Prior to entering medical school Dr Barrett studied ecology and biological sciences, and these two fields continue to inform her clinical work. She has served on many committees addressing maternal and infant health issues including the National Breastfeeding Advisory Committee for the New Zealand Ministry of Health and the Infant Feeding Advisory Group for Health Canada. She is a member of the Professional Advisory Group of La Leche League New Zealand.
Home Birth Aotearoa advocates for exclusive breastfeeding where possible for all babies. The health and well being benefits of breastfeeding are significant and lifelong – we could dedicate a whole website to this topic! Successful establishment of breastfeeding has a significant impact on the breastfeeding and bonding for mother and child. Birthing at home gives you an excellent opportunity to naturally establish breastfeeding in a comfortable and familiar environment.
Most people believe that babies need help to breastfeed, however, a healthy term baby, born by normal vaginal delivery without any medication, can decide for themselves when they are ready to take their first feed. It has been found that infants are 8 times more likely to breastfeed spontaneously if they spend more than 50 minutes in skin to skin contact with their mother immediately after birth.
If the baby is placed on their mother’s abdomen and left for at least 60 minutes, they will begin a 5 part sequence:
- For the first 30 minutes (approximately) they will rest and peer up at their mother.
- Between roughly 30 – 40 minutes, the baby will start lip smacking and mouthing their fingers, followed by an outpouring of saliva onto their chin.
- He or she will then begin to inch forward up the mother’s abdomen, pushing strongly with their legs, as they move upwards, they will often turns their head from side to side.
- When they reach mother’s sternum, they will bounce their head (head bobbing) into her chest.
- As they come close to the nipple, they open their mouth widely and after several attempts, attach to the breast perfectly. Babies who attach in this way have fewer problems with breastfeeding.
The baby uses the smell of amniotic fluid on their hands to make a connection with an oily substance secreted on the areola to guide their way. If the breasts are washed it will interfere with this sequence of events.
This natural sequence of events also helps the mother. The baby pushing their feet on her abdomen may help the expulsion of the placenta. The stimulation and suckling of the breast helps to release a surge of the hormone oxytocin which helps contract the uterus thereby expelling the placenta and closes off many blood vessels thereby reducing bleeding. The suckling also results in the production of the hormone prolactin, enabling further milk production.
The act of skin to skin contact also enhances the bond between mother and baby.
Getting a good latch
Ensuring that the baby is latched correctly and comfortably is the most important aspect of breastfeeding, as this ensures that baby is effectively taking milk from the breast, and that breastfeeding is comfortable for mum. A wide open mouth, with babies nope to the nipple should ensure a good latch. Trust your baby and your own instincts when latching.
Newborn babies have the ability to see from the breast to their mother’s face. They can recognize their mother’s face as early as 4 hours following birth. They tend to favour circles rather than squares and are able to distinguish between light and dark. This fits with the special interest the baby has for the areola.
Sounds travel easily through the uterus. Infants are most responsive to human voices. They have learnt the sound of their mother’s (and father’s) voice before birth and are most soothed by it.
A baby is born with 3 reflexes important to breastfeeding:
- The rooting reflex is when something touches the baby’s lip or cheek and he opens his mouth and turns to find it. He puts his tongue down and forwards. This reflex is usually present from 32 weeks gestation.
- The sucking reflex is stimulated when the baby’s palate is touched by a nipple, teat or finger.
- The swallowing reflex occurs automatically when the mouth fills with milk.
These reflexes happen automatically in a healthy term baby without him having to learn them and are usually well coordinated enough for him to feed successfully very soon after birth.
If we consider the baby’s reflexes and behavioural sates, we can consider the best times to offer breastfeeds and how to stimulate the baby’s interest in breastfeeding.
As mentioned earlier, initially after birth, the baby is in an alert and responsive state and is likely to make a successful first attempt at breastfeeding. If the baby has an early successful feed it has been found that the mother is more likely to breastfeed for longer; if that feed is delayed it is less likely to be successful. Therefore, the optimal time for the first breastfeed is the first 30 minutes to 1 hour after birth. It is not necessary or helpful to try to force the baby to feed, but to recognise rooting and other signs that the baby is ready to feed.
After this initial period of alertness, many babies enter a long state of quiet sleep where they become difficult to rouse for feeding. It is thought that this nature’s way of allowing the mother to rest after the exhaustion of labour and the baby following the stress of being born.
Observe your baby for periods of REM sleep when they can most easily be awakened and thus encouraged into breastfeeding through stimulation through skin to skin contact. You may also observe them stirring and making hand to mouth movements showing that they may be ready for another feed. Crying is a late indication of hunger and the baby’s movements are likely to be disorganised so they cannot feed effectively and may fall asleep before much milk transfer has taken place. Forcing a baby to breastfeed will often result in breast refusal. The mother and baby need to remain in close contact after birth, rather than the baby being removed to a separate room.
Immediately after baby is born:
- Request skin-to-skin contact with your baby as soon as possible after he or she has been born. If you are unable to do this yourself, ask that baby has skin-to-skin contact with your partner.
- Nipple tenderness is normal for some women. Intense pain is NOT. Seek skilled help early to prevent damage to your nipples. A lactation consultant, La Leche League Leader or Peer Counsellor has those skills. Please also see the links at the bottom of this section for where to go for more help.
- Day 1: baby will have about around ½ teaspoon of colostrum (the early, yellow/gold milk) each feed, around one wet nappy and sticky green-black poo.
- Day 2: Approximately 1 teaspoon of colostrum each feed, around 2 wet nappies and soft green-black poos.
- Day 3: breastmilk is starting to increase, around 3 wet nappies and poos are becoming greenish-brown and less sticky.
- Day 4: 4 wet nappies and poos becoming a lighter green-brown or may have changed to a mustard-yellow and can be ‘seedy’ or watery.
- Day 5: breast milk supply increases, around 5 wet nappies and poo mostly mustard-yellow, soft or liquid 3-4 times every 24 hours.
- Day 6: onward, 6-8 clear wet nappies and about 4 poos or more is all normal in 24 hours.
The first few days and weeks
- Expect to spend lots of time sitting down, feeding your baby!! It is normal for newborns to need around 12 feeds in 24 hours. You and your baby are working hard to get the right amount of milk.
- It can take 6-8 weeks for the breastfeeding ‘dance’ between mum and bay to find its rhythm. Each baby/mother pair is unique with different patterns, so try not to compare yourself or your baby to others. Just like adults, all babies have different eating patterns.
- There are usually lots of questions, from both parents, so your breastfeeding support network is very important at this time.
- Accept all offers of help from friends and family – you deserve it!
- You may like to check out local support groups, where you will meet mums with babies of all ages, with similar questions and experiences.
- Going out with your breastfed baby is easy. You have baby’s food ready to go, at the right temperature, in sustainable and attractive packaging!
- Have your nappy bag packed ready at the door – nappies, wipes, perhaps a baby sling and a change of clothes are really all you need.
- If your baby is hungry while you are out, feel free to breastfed him/her wherever you feel comfortable.
After the first few weeks:
- From around 6 weeks, some mums find they have lost that ‘full’ feeling in their breasts and start to question whether they have enough milk. What is actually happening is that your milk supply is starting to match the needs of your baby – clever you!
- Solid foods can be introduced at around 6 months, with breastfeeding still forming a significant part of baby’s diet until around 12 months old. The World Health Organization recommends that babies continue to receive breastmilk for 2 years, or more, as long as mother and child wish.
- Returning to work – explore childcare options that are going to be compatible with your family needs and supportive of caring for a breastfed baby. You don’t have to stop breastfeeding just because you go back to work.
The above information is adapted from resources provided by Denise Ives, Breastfeeding Counsellor and general legend. Denise’s site, Mummy Milk is a fantastic resource for information on breastfeeding.
Reliable links for breastfeeding information
Kelly Mom: A wide variety of articles based on best practice and up to date research on breastfeeding.
La Leche League New Zealand is an international mother to mother network of breastfeeding support. Most cities and towns have at least one La leche branch, where pregnant women and mothers are welcome to come for support and friendship.
The Baby Friendly initiative is an organisation established to help make breastfeeding the norm in New Zealand. They have lots of links with the community for support of parents and professionals.
The Australian Breastfeeding Association has a range of articles and information from preparing before baby is born into toddlerhood.
Piripoho is a milk sharing site for women wanting to donate or seeking breast milk as an supplement.