Birth is a woman’s right and how she chooses to go through her pregnancy and how to give birth should always be in her control. If you're on your first pregnancy, no doubt you have been reading countless books, been getting advice from medical professionals and recommended by family and friends what you should do.
During pregnancy, there are tests and scans that are usually carried out. Having them is not obligatory. You can say ‘no’; tough many don’t realise that there is a choice. Rarely are parents told of the risks and benefits of each test before having them carried out.
The medical professional is there to advise and inform you of your choices; however the ultimate decision should always lie with you. Here are some considerations that you might want to think about:
Where to have your antenatal check-ups
Your antenatal care can be provided in a number of ways. You could book your appointments at the local Children’s Clinic, you could be assigned a visiting community midwife at your local doctor’s surgery, or you may have your antenatal care directly with the hospital at which you will give birth. Ask about each option to find out which option would best suit you.
Dating Scan – the rigidity of it
Often women will calculate their due date based on their last menstrual cycle. Then at the first scan, which is around 12 weeks into her pregnancy this date is likely to alter. Note that scans aren’t always accurate and the due date can often out between 3-5 days. If they measure the baby bigger, then this would give a mum an earlier expected date, which at the end of pregnancy means an earlier date for potential pressure for an intervention/induced birth.
It’s worth noting here that the World Health Organisation states that a baby is at full term from 37 weeks and if born at this point usually doesn’t need medical assistance. Yet it is also perfectly normal for a woman to give birth around the 42 week mark. So the rigidity of a single day is nonsense when you think about it. Only 4 per cent of babies are born on their due date, and the majority of babies are born after their due date.
Also be aware that having scans is not compulsory, in fact some might argue that as they don’t alter the course of pregnancy, is there really a need for them at all? For many women, they provide reassurance that the pregnancy is progressing well, however for others, the results of a scan can bring unexpected news. How does this alter how the woman feels in pregnancy? If you would like to read more about Ultrasounds, I recommend the book written by the Association for Improved Maternity Services (AIMS) called Ultrasound? Unsound
Gestational Diabetes test
Gestational Diabetes is a high blood sugar condition that women can get during pregnancy. Between 2 and 5 per cent of pregnant mothers develop this condition.
Only about 30 per cent of women who test positive on the glucose screen really have the condition. If you test positive on the screening, you'll need to take the glucose tolerance test (GTT) – a longer, more definitive test that confirms whether you have gestational diabetes, or not.
How will I know if I might have gestational diabetes?
A routine urine test will show a lot of sugar in your urine. If midwife notices this, she may want you to be tested for this. Even if the results are normal, you may be screened again at 24 to 28 weeks, just to be sure.
If you are diagnosed with Gestational Diabetes, your pregnancy will move into the ‘high risk’ category, which in turn could mean birth choices being taken away from you; such as no longer being able to give birth in a birth centre or midwife-led unit. The reason for this is that with gestational diabetes babies can grow bigger than the expected range for birth and the health system would prefer to monitor you in the labour ward, where facilities are on hand should they be required.
This is why it is important to maintain a healthy diet throughout pregnancy, so that your blood sugars remain in the normal range. Avoid sugary foods and drinks before midwife appointments to avoid unusual readings that could lead you along this path.
Where to have your baby - hospital, midwife-led unit or home birth?
In the UK, the NHS, in fairness, is trying hard to normalise birth (read about the Better Births Initiative). While many births still take place at hospital, the NHS is working towards making it less of a medical procedure and more of the wonderful experience that it should be treated as. The NHS is investing in more birthing centres, many of which are within a hospital setting. The centre usually has a more hotel-like feel rather than the medicalised setting that a labour suite tends to have. The centres are managed only by midwives, which is why they only accept women with low-risk pregnancies.
Women who are considered high-risk would be in a labour ward, where obstetricians are available to help, should any emergencies arise.
In recent years there has been a push for home-births. In the Better Births Initiative link (above) it states: ‘Birthplace research shows that healthy women with planned births in midwife-led units and at home were more likely to have a normal birth as compared with obstetric units.’
Home Births are intended for women who have had low risk pregnancies and where midwifery care comes to your home to help you in give birth to your baby.
So is where you birth really a choice? What if you did have factors that put you in the high-risk bracket…are some of those choices no longer available to you? Each woman’s circumstance is different, so speak to your midwife about your plans for birth to see how they can accommodate your preferences.
Should I take their advice for an induced labour or can I wait for labour to start spontaneously?
As your due date approaches, your midwife is likely to say to you something along these lines. ‘If baby hasn’t arrived before so-and-so date then we will book you for an induction’. Please stop her right there and simply ask the question, ‘Why? What medical concerns do you have for me or my baby?’
According to the National Institute of Clinical Negligence (NICE), an induction should only be suggested to mothers when there is a clinical justification – read the NICE guidelines. If all is well and your baby is happy where they are and you both just happen to be past the due date, this is NOT a reason for induction. However, many women just aren’t aware of this.
Because it has become so routine in our modern society, women seem to accept this as the way it has to be, without questioning why. For those who haven’t read up on their choices, they may easily accept this information and just say to friends and family. ‘I’m going to be induced on so-and-so date.’ But what they are not told is what the medical reason is for this. The late arrival of a healthy baby, with a mother who is not presenting any medical concerns, is not a clinical justification.
Quite often women aren’t talked through what an induction really means, how this type of labour feels, compared to a spontaneous labour, and what risks are involved during an induced labour. In many cases an induction leads to a C-section. I often wonder if these outcomes could have been avoided, if they had been given more time for a natural labour to start.
Just think back to when you first fell pregnant? Did you calculate your own ‘due date’? Perhaps this date was a day, or more, later than your hospital due date… are they therefore rushing you to have your baby unnecessarily early? You, your body and your baby have done just fine for 39+weeks so why do they think that your body wouldn’t know how to go into spontaneous labour when it is ripe and ready?
So what can you do? You are fully within your rights (because how you birth is YOUR choice) to decline induction and be asked to be monitored more closely in the days after 40 weeks has passed, to ensure that both you and baby continue to be well. For extra reading, look at the AIMS booklet on Inducing Labour: Making Informed Decisions
The choice of how your labour plays out is in your hands - it doesn't need to be totally managed by the midwife, neither do you need to be left totally alone. It can be a blend of many things. Here are some things to consider:
In the hospital you may be asked to sign consent forms when you are in established labour, say for example agreeing to an epidural. It may be worth discussing these options with your midwife in early labour and tell her what you are open to or not. Get those consent forms signed before you enter the bubble of established labour, when the last thing you are going to care about is admin! You will have a bigger job at hand.
A vaginal examination helps the midwife establish how far your cervix has dilated. Other than that, it serves no purpose. It is possible for the cervix to constrict in labour if a woman is feeling tense or vulnerable. So if you are not comfortable with having an examination, the cervix may react and present tighter than when you relax your body; therefore giving a misleading dilation stretch. Though not very likely, there is a slim chance that by having a vaginal examination infection and bacteria is introduced into the vagina. An expectant mother is well within her right to decline all vaginal examinations, if that is her preference.
Breaking your waters vs spontaneous rupture of the amniotic sac
In an induced labour, after the pessary has taken effect, if labour isn’t progressing as they would like, the next step would be perform an Artificial Rupture of the Membranes (ARM), also known as an amniotomy. This is usually carried out by your midwife. The membranes will be ruptured using a tool, such as an amnihook or amnicot. This is carried out in the belief that it will speed up and strengthen contractions.
In a spontaneous labour the membranes can rupture at any point in labour. In rare cases a baby is born with amniotic sac still intact, this is called ‘en caul’.
While the risks are very low, there are risks associated with ARMs. It is a blind procedure, therefore, there can be no certainty that the midwife won’t end up rupturing vessels that are part of the overall blood supply to the baby. An already compromised baby may be put at further risk by an amniotomy; as the uterus could become hyper-stimulated.
In addition to this, if when the waters break the baby doesn’t align correctly within the pelvic inlet, they maybe might find it hard to get into position. When this happens, the cervix dilation can stall and labour doesn’t progress as it should do. Most hospital’s policies are that they would like babies to be born within 24 hours of the ARM. If a woman’s labour shows signs of stalling, other forms of induction and augmentation will be offered, before the 24 hour deadline approaches.
Your baby should be monitored at least every four hours in early labour and every 15 minutes in established labour. A midwife will listen in to the baby’s heart rate, either with a hand-held Doppler or with a continual fetal heart monitor and check that baby’s heart rate does not decelerate during contractions. When a baby’s heart rate dips during contractions, it is a sign that the baby is in distress. They will continue to monitor you and the baby very closely and advise if alternative action necessary.
Confined to the bed vs being mobile
When a woman spends most of her labour on a bed, her movements are restricted, her body could be in the exact same position for long periods of time. If this happens to be more lying down than sitting upright, she is not using gravity to her advantage and she could be slowing the labour process down without realising it.
A woman, who wants to encourage a smoother labour, keeps mobile. Those movements encourage the baby to descend more rapidly and result in shorter labours, often without complications. Antenatal educators advise all mothers to be active and upright in labour and to only use the bed when it is absolutely necessary.
Natural vs medicalised pain relief
There are two types of pain relief; see the options below:
Women are encouraged to go through as much of labour with natural pain relief, so as not to interrupt the natural process of birth. However, for some women, using medical pain relief is a necessity and we are lucky to have these options available to us, should they be needed.
Some people consider hypnobirthing as a natural form of pain relief. Hypnobirthing itself doesn’t promise a pain free labour, but many women who have learned hypnobirthing, who have practiced the techniques and have worked on preparing for birth with a positive mindset go on to experience wonderful births.
Giving birth; should I lie, sit or squat?
Unlike the films and soap operas, giving birth on a bed with your legs astride is not the only position to give birth. The sitting position on a bed can inhibit your baby’s entrance into the world and it can be more challenging for the mother to give birth in this position. Lying down flat, means that you are not letting gravity help you and somehow your baby has to venture into your birth canal horizontally – this isn’t very efficient.
Consider being more upright, think about adopting a squat-like pose, where you are able to bear down, allowing the birth of the baby to be smoother. This could be sitting on a birth ball with your hips higher than your knees (encouraging the upper part of your body to tip slightly forward). This position puts the baby’s weight on the frontal part of the pelvis; potentially allowing more space. This is because your ligaments are looser during late pregnancy and your pelvic capacity can widen.
You could also think about being on your knees and leaning across the back part of the bed (moved into a vertical position - like the back of a chair). By leaning over the bed, you are allowing your bump to tip forward, whilst still having movement and flexibility in your hips. This position also works well if you are in the birthing pool.
Coached birthing vs mother-led birthing
You may have visions of the midwife encouraging you to ‘push’ your baby out when the time comes. Media will have you believe that labour is all about pushing, pain and panting – this is inaccurate. A mother doesn’t need to experience that to birth her baby; there are gentler ways to aid your baby into this world. Simply by listening to your body and responding accordingly; through gentle Down Breathing, as taught in KG Hypnobirthing, allows your baby to descend to the rhythm of your body.
Natural expulsion of the placenta or Synthetic Oxytocin injection
It is entirely up to you whether you prefer the midwives to administer Synthetic Oxytocin into your system to help aid the detachment of the placenta from the uterus wall. If you have had an unmedicalised labour up until that point, you may well choose not to accept the injection to start with. It is extremely likely that your body will do this of its own accord. If you have had an augmented labour, then your body may then need a little help in expulsing the placenta, with the help of this hormone substitute. Ask your caregiver if they feel it is necessary when the time comes, or perhaps wait to see how your body reacts after birth to decide for sure.
Cutting the cord / Optimal cord clamping
In the UK today, optimal cord clamping is encouraged for all babies in all birth situations, whenever possible. Ask your midwife what the policy is in your Trust. My hope is that they will say ‘until the cord stops pulsating’. If they don’t say this, then maybe this is something that you need to have in your birth plan. Nature intends for the baby to have all the blood from the placenta after birth. When the blood has drained, the umbilical cord starts recoiling and the placenta begins to detach from the uterus wall. At most this takes a few minutes. During this time the baby is enriched with all the stem cells and blood that belongs to him/her, that they would otherwise be deprived of, if the cord were to be cut sooner. Did you know that a baby can weigh 200g more if the blood is passed from the placenta, than if the cord were to be cut immediately? This blood belongs to your baby, so ask your caregivers to ‘wait for white’ (the colour the umbilical cord will be when the blood has passed through). Find out more: Wait For White
Skin to Skin
It is encouraged that the baby goes directly to the mother straight after birth. Decide if you prefer to have the baby wiped down first or whether you are happy for baby to come directly to you. This is known as Skin to Skin. This period is extremely important for many reasons:
After being nine months in a warm, dark pool of water, where the sounds are all muffled. It is quite a stark contrast to come into this world. Where people are excitedly talking about the new arrival, where the lights are bright and this beautiful wet baby is starting to feel cool air on its skin. The best way to soothe the baby is to place it directly to the mother’s chest, where her body heat can warm the baby, where the sound of her heartbeat and other bodily noises can be heard again; offering comfort and where a significant part of the microbiome process can be introduced (this is one of the early milestones in which you can colonise the gut with important bacteria from the mum and helps to build the baby’s immune system).
If for whatever reason mum is unable to do this, then the Birth Partner could do this. Isn’t it much nicer than having the baby in a cot nearby, or being held by strangers, when there is no need?
Breastfeeding is a personal decision, and from experience I know that it isn’t as easy as it seems. What your plans may have been before you baby was born, can be very different from what you actually experience. However, breastfeeding is considered beneficial for the following reasons:
Partners being able to stay
This varies from hospital to hospital. It seems crazy that when a woman who is in a vulnerable situation and needs support, is not allowed to have her partner stay with her. There must also be an emotional impact for the partners to be sent away, when it comes to bonding with their baby. Discuss this with your midwife, as to what the guidelines are for your hospital. Sometimes you can pay for a private room; this option may be attractive to you.
These are just some considerations to decide upon, that can help you create the right birth plan that is for you.
If you have any questions, feel free to email: Magical Baby Moments at firstname.lastname@example.org
Magical Baby Moments offers group hypnobirthing courses in Romford and Upminster, and private courses across Essex and London. Check to find out upcoming dates.
The Microbiome Effect by Toni Harman and Alex Wakeford is a fascinating book of emerging research that indicates how vital bacteria are for human health. A baby's exposure to them during labour, birth and beyond helps kick-start their developing immune system. This book reveals the impact of babies born via Caesarean Section (C-Section) and how this potentially alters the course of their immune development and makes them more susceptible to non-communicable diseases.
Here is my synopsis, of what I believe is a must-read for all birth educators and expectant parents, to understand the intricacies of a vaginal birth and the vital components that help your baby thrive in the outside world.
Human bodies are comprised of trillions of human cells and microbes (bacteria, viruses, archaea, fungi etc). These cells and microbes live on and inside us. The bacteria inside our body help keep us functioning properly and give us the ability to fight off diseases. However, modern ways of living, such as diet, antibiotics and C-sections - to name a few - are adjusting the diversity of microbiomes in the human body. Current research indicates that this alteration in the way we live is giving rise to many common non-communicable diseases such as allergies, asthma, auto-immune disorders, diabetes, obesity and more.
For a long time, antenatal educators have explained to its parents-to-be the benefits of a vaginal birth vs a C-section birth, in regards to babies breathing abilities. In a vaginal birth, the birth canal compresses the lungs to expel the liquid that has been in them during pregnancy; so that once earth-side, the lungs are fairly clear of liquid and breathing unassisted comes more easily.
The research conducted, which is discussed in this book, digs deeper. It looks into many other vital stages that a baby encounters during a vaginal birth, which can impact his/her long-term health positively. Other scientific tests are indicating that there is a link with an imbalance in the human microbiome (often caused via Caesarean section deliveries) and with chronic non-transmissible diseases.
It is believed that during pregnancy a baby lives in a near sterile environment and exposure to microbiomes is minimal. It is during a vaginal birth, once the amniotic sac had ruptured, that a baby begins to be exposed to bacteria. This is when it comes into contact with vaginal, faecal and skin microbes. These enter the baby's eyes, ears, nose, as well as being swallowed through the mouth. This prenatal exposure is one of the main seeding events for the baby's gut. Once the baby is born it will come into contact with more bacteria - from the air in the place of birth, from the skin of its caregivers and parents etc. All of these encounters help to colonise the baby's gut.
Babies born via a Caesarean section (C-section) potentially miss out on this exposure, if the amniotic sac hasn’t ruptured, because they won’t come into contact with the mother’s vaginal or intestinal microbes. As a result the baby’s gut microbiome composition will be different.
Latest research favours infants that are born via C-section to have skin-to-skin contact and breastfeeding where possible, because the second major influx of microbes is during these two events (babies born vaginally are also recommended to do this too).
During skin-to-skin contact, and when a baby is looking for milk, it will open its mouth and suckle or lick the mother’s skin. A mother’s breastmilk is incredibly rich. It provides essential nutrients for the baby's growth and development, including key immune components and sugars. The sugars not only provide energy for the baby, but it also feeds the bacteria in the gut, quickly colonising it and preventing other harmful bacteria from taking hold. These events and opportunities to come into contact with the right bacteria kick-starts the continued development of the infant immune system. The bacteria teach the immune system to recognise friendly and harmful bacteria, and know what to attack, or not.
In contrast, a baby that is fed formula milk will only receive the nutritional benefits. This milk is missing prebiotics to feed the gut microbes. It also lacks the right bacterial species and immune components that the developing baby needs. These missing components could impact the training of the infant immune system, which could mean health implications later in life.
All the way through pregnancy, labour, birth and infancy things are supposed to happen at certain times. When the birth process is interrupted with medical intervention, the evolution of the immune system is disturbed, which could result in it malfunctioning later in life.
Research has also shown that the microbial profile of a baby born vaginally resembles that of its mother, and continues to do so with each generation that is born vaginally. However when this pattern is interrupted by a C-section delivery, the child may not match the mother’s microbial profile and the child may fail to inherit critical “keystone” species of bacteria to ensure good health. C-sections could be contributing to key microbe species being lost, making us more susceptible to pandemics.
Other evidence suggests a correlation in C-section babies having a higher risk of developing asthma, type one diabetes or coeliac disease, and of becoming overweight or obese. This is not to say that all babies born this way will go one to develop any of these, they are simply more susceptible. What we don’t know yet is the ongoing repercussions of this.
So what can we do about it?
As an antenatal educator, I feel it is my duty to inform my parents of the potential health implications of babies born via a C-section. Parents need to better understand the importance of vaginal births, as a way to ensure that their baby receives the necessary exposure to bacteria, which will help colonise its gut in the right way - to ensure a fully functioning immune system.
There will always be world in which some babies are needed to be delivered via C-section, therefore what steps can the caregivers take to help the baby receive optimal seeding and feeding? Mothers can be tested to see if they are suitable for “swab-seeding” (this is currently under a strict protocol). However for the feeding aspect, there is now no reason why babies cannot be passed to mothers straight away in all elective C-sections (and some in emergency C-sections); so that the baby can have skin-to-skin contact and have the opportunity to begin breastfeeding. This will allow the baby to be exposed to essential bacteria and microbes and helping to kick-start an immune system that could keep them healthy throughout their life.
This article only scratches the surface and highlights the key points of the book. I strongly recommend mothers to read it and learn more about it. Ask your midwife and/or obstetrician how much they know about this subject. If they don’t know too much about this subject, politely ask them to do their research. Your baby’s life is in their hands.
The Microbiome Effect is published by Pinter and Martin.