Author Archives: Janelle Durham

About Janelle Durham

I teach Discovery Science Lab and Family Inventors' Lab, STE(A)M enrichment classes in Bellevue, Washington for ages 3 - 9. I am also a parent educator for Bellevue College, a childbirth educator for Parent Trust for Washington Children, former program designer for PEPS - the Program for Early Parent Support, and a social worker.

Why is induction recommended over age 35?

What is induction?

Induction is using medical means to start a labor that hasn’t started on its own. (Learn more about methods of medical induction.)

Induction may be recommended if: the baby is not growing well or thriving in utero, the parent has an illness that is worsening (such as diabetes or hypertension), the baby is overdue, or the bag of water broke and labor hasn’t started on its own. There is also a category called elective induction, which is being induced for non-medical reasons, such as wanting to control the timing of the birth or being tired of being pregnant.

As with all medical interventions, induction has benefits and risks. If there is a clear medical indication that delivering the baby sooner rather than later would have more benefits than the risks of induction, then induction is recommended.

How Common is Induction

Induction rates rose steadily from 1990 to 2010 ((source for chart), then somewhat plateaued, following some active campaigns to reduce elective induction, such as AWHONN’s “Don’t Rush Me – Go the Full 40” about the physiologic benefits of full-term pregnancy, and an editorial in American Family Physician about stopping elective induction before 39 weeks to reduce unintended harms to babies not yet ready for birth.

Chart showing trends in labor induction. Steady rise from 9.5% in 1990 to 22% in 2005, then somewhat plateaued. Jump from 23.8 in 2010 to 31.37 in 2020.

In 2014, ACOG’s recommendation was to induce at 41 weeks.

That changed after the results of the ARRIVE trial were published in 2018. The ARRIVE trial was considered a high quality randomized controlled clinical study (although ACNM did caution against over-generalizing the results, this article addresses methodology concerns, and this infographic addresses how the results might not apply to all people.)

The results of that trial (and other trials) were that elective induction decreased the risk of cesarean. (Rates were 18.6% in the induction group versus 22.2% in those assigned to the wait for labor to begin group.) The induction group was also less likely to have gestational hypertension / preeclampsia (9% vs 14%).

ACOG (the American College of Obstetrics and Gynecology) issued guidance in response, and a joint statement from ACOG and SMFM (Society for Maternal Fetal Medicine) said ““ACOG and SMFM have … determined that it is reasonable for obstetric care providers to offer an induction of labor to … Women who are planning their first delivery, are healthy and have no medical or obstetrical complications… who are 39 weeks pregnant and had an ultrasound performed early in the pregnancy to confirm dating.”

In other words, elective induction at 39 weeks is back on the table as an option after 2018. In 2016, 24.5% of US births were induced. In 2021, 32% were.

There was not universal agreement with this recommendation: WHO says there’s insufficient evidence to recommend elective induction before 41 weeks and NICE says induction should be offered at 41 weeks. SOGC (Society of Obstetricians and Gynaecologists of Canada) said we shouldn’t recommend induction just to reduce cesarean risk, ACNM (American College of Nurse Midwives) said there are benefits of spontaneous labor and risks of induction and other effective ways to reduce the risk of cesarean (e.g. doulas, midwifery care, movement during labor)

Is induction recommended for parents over age 35?

In a 2022 consensus statement on Pregnancy after Age 35, ACOG made a more explicit move to recommend induction for older moms: “We recommend proceeding with delivery in well-dated pregnancies at 39 0/7–39 6/7 weeks of gestation for individuals with anticipated delivery at age 40 years or older due to increasing rates of neonatal morbidity and stillbirth beyond this gestational age.” A randomized trial of induction at 39 weeks for women over 35 also indicated no increased risk of cesarean and no short-term adverse effects on mothers or babies.

Stillbirth Risk

How high is the risk of stillbirth for mothers over age 35? How much higher is it if the pregnancy continues past 39 weeks?

This chart (source) compares the risk of stillbirth per 10,000 pregnancies during each week of pregnancy for pregnant people under age 35 vs. for people 35 years or older. It is clear that the risk does increase each week, and that it is much higher after age 35.

Weeks<35 yrs>35 years

[Note: if you’re a pregnant person reading this, I know that numbers like this can be frightening. Take a deep breath, and flip the numbers: even a rate like 32.5 per 10,000 means that 9,967 out of 10,000 will NOT have a stillbirth in week 42.]

Benefits and Risks of Induction

So, the research cited above indicates that inducing at week 39 may reduce the risk of stillbirth, possibly reduce the risk of cesarean, and can reduce the chance of hypertension or diabetes worsening.

What else does the research show us about the risks and benefits of induction? A Cochrane review, which mostly looked at induction at 41 weeks vs. continuing to the 42nd week, showed:

  • fewer perinatal deaths / stillbirths
  • better Apgar scores at birth, and fewer NICU admissions
  • little to no difference for: perineal tears, postpartum hemorrhage, breastfeeding at discharge

But, induction is not innocuous. What are the risks or tradeoffs of induction?

  • Medicalization: An induced birth is inherently more medicalized than waiting for labor to begin spontaneously – continuous fetal monitoring is required, IV fluids are common – these two factors can also reduce the birthing parent’s ability to move around and use natural coping techniques. Plus they may not be allowed to eat solid foods. ACNM summarizes this as “Based on US practices, induction may not be a desirable option for those persons who prioritize a… low-intervention birth experience.”
  • Not waiting for baby to trigger labor: In the final weeks of pregnancy, babies are gaining immunities, gaining weight, increasing their brain development and maturing their lungs. When the baby’s lungs are mature, that triggers hormones that trigger labor. If we induce labor before that happens, there is a chance that baby is not as ready for birth as they would be if labor started spontaneously. At 39 weeks, many babies are totally ready to go, but not all.
  • Longer labor / hospital stay: In late pregnancy, prostaglandins cause the cervix to ripen and thin. If we jumpstart labor, the body may not have made these preparations for labor. So, with an induction, it can take a while to get labor started. It might take 12 – 24 hours, or longer if cervical ripening is needed. If an induction takes too long, cesarean may be recommended.
  • Changes to the hormonal dance of labor. Typically, in late pregnancy, the uterus becomes more sensitive to the oxytocin hormone which causes labor contractions. During labor, as the cervix stretches, pain receptors in your brain release endorphins, a natural painkiller more effective than morphine. When labor is induced with Pitocin (synthetic oxytocin), your body does not produce as much natural oxytocin and does not produce as much endorphins, so you miss out on that natural pain relief. (Learn more about the hormonal differences.)
  • More Pain? I have not been able to find any research comparing average pain levels in an induced labor versus a spontaneous labor. (Nor much on maternal satisfaction, although it seems to me that both of these things are important factors that we should be researching.) Anecdotally, many people seem to experience more pain in an induced labor. That may be partially due to the fact that a natural labor builds intensity gradually, allowing you to adapt and find coping techniques thar work for you. With a Pitocin induced labor you jump straight into long, strong contractions. (3 – 4 contractions in ten minutes, each lasting 40 – 60 seconds.)
  • Induction can cause variations in the baby’s heart rate, which can lead to additional interventions.

Questions to Ask

If your care provider has offered induction at 39 weeks, here are some questions you can ask yourself or them to decide if it’s right for you:

  • Are there other ways to reduce risk of stillbirth or monitor for other problems with my baby?
  • Are there other ways to reduce the chance of cesarean birth? There are: having continuous labor support (especially from a doula), upright positions and movement during labor and birth, choosing a midwife rather than an OB as your care provider and waiting until 6 cm dilation before being admitted to the hospital are just a few. (Learn more.)
  • Are there non-medical ways to get labor started? Possibly sexual intercourse, definitely breast / nipple stimulation, possibly acupuncture, herbs, or castor oil. If the need to start labor is urgent, your care provider may tell you these aren’t effective enough. But, if you have some time, they may say these are options you could try.
  • How likely is induction to be successful? If you’re almost ready to go into labor on your own, induction will be faster and more effective than if you’re not. So, learn about the Bishop score which measures ripening and effacement of the cervix and ask your caregiver what your score is. Starting Pitocin only when you have a Bishop score of 4 increases the chance of cesarean. Waiting for your cervix to get ready naturally, or using cervical ripening methods to get your Bishop score up to 8 or higher (if it’s your first baby, 6 or higher if you’ve given birth before) will increase the chance of a successful induction. (Learn more about this and other factors here.)

How to have the best possible induction?

If you do decide that induction is the best answer for you, here’s how to increase your satisfaction:

  • Ask your care provider what method(s) will be used, and learn more about them.
  • Be prepared for a long process. Pack some entertainment options and plenty of patience. Consider having an extra support person so they can swap off or take breaks.
  • Eat before your induction begins, as you may not be able to eat after it begins.
  • Create an environment that is as calm and soothing as possible: perhaps dim light, music playing, favorite items to wear or look at or hold.
  • Try to be as mobile as possible (this helps baby rotate and descend which helps labor to progress.) For example, try sitting on a birth ball or in a rocking chair rather than lying in bed.

Learn more about interventions in maternity care and making informed choices in episode 8 of the Transition to Parenthood Podcast, or by reading Pregnancy, Childbirth, and the Newborn: The Complete Guide.


Teaching Music as a Comfort Technique

pregnant woman listening to music on headphones

Many childbirth educators include background music within our classes – maybe we have energizing music playing as people arrive or over break, maybe we use relaxing music during relaxation techniques, maybe we use it as one of the tools during an ice exercise. Or we vaguely mention that you could have a birth playlist prepared. But I think it tends to be a background thing. How often do you explicitly talk about music in pregnancy, labor and postpartum and what the benefits are?

It turns out there is actually some good research into music in the perinatal period.

Music During Pregnancy

Several studies have shown that listening to music during a non-stress test reduces the parent’s anxiety and improves the results of the NST. (RCT by Catalgol, RCT by Oh, RCT by Soylu, trial by Dolker and RCT by Garcia-Gonzalez et al). With clearly proven benefits, and no risks, this seems like an easy thing to suggest. And while all these studies were in the context on an NST, one might be able to guess that listening to music during other stressful procedures or any time during pregnancy might also help reduce anxiety and improve baby’s responsiveness. Again, with no harm, is it worth sharing this idea?

One quasi-experiment found that when women in their third trimester listened to relaxing music with a tempo of 60 beats per minute for just 15 minutes, their anxiety level was significantly reduced. There were additional studies that looked at parents participating in music therapy sessions in their home and/or prenatal music classes. (cited in McCaffrey, et al)

Music During Labor

  • Dance and music combined and music alone both reduced pain and fear during active labor. (RCT by Gonenc and Dikemen)
  • Listening to music during labor led to lower levels of pain and anxiety, improved fetal heart rate and less postpartum analgesia. (RCT by Simavali, et al.)
  • Listening to music reduced pain and anxiety during latent phase, but no difference during active labor. (RCT by Liu et al)
  • Listening to music during labor reduced pain levels during active labor and at one hour postpartum, and decreased anxiety in active labor, second stage and one hour PP. (RCT by Buglione, et al)
  • In a systematic review and meta-analysis by Santavinez-Acosta, (they use the term “music therapy” but I believe the included studies were all listening to music) they found: less pain during latent and active labor, less post-cesarean pain, less anxiety during labor and in the first 24 hours, less pain meds after cesarean.
  • Another systematic review by Chen (note, there may be some overlap in the studies reviewed by this and the prior listing) showed lower anxiety, less depressive symptoms, lower pain and better blood pressure.
  • An integrative review by McCaffrey, et al, showed 15 out of 20 studies showed statistically significant decrease in pain, and four showed a decrease. 8 of 11 studies showed statistically significant decreases in anxiety. Music also promoted relaxation and decreased stress. Two studies showed faster labor progress.

Reasons posited for why listening to music reduces pain:

  • When music enters the ear, it stimulates the hypothalamus to produce dopamine and reduces cortisol. Causes the pituitary gland to release endorphins which decreases pain.
  • Gate control theory of pain – non-painful stimuli (music) close the nerve “gates” so less of the painful stimuli reach the brain. (Distraction.)
  • Positive memories may be associated with the music.

None of the studies showed any adverse effects or unfavorable outcomes.

Music and Cesarean:

Listening to music before surgery led to increased positive emotions, decreased negative emotions and lower blood pressure (RCT by Kushnir, et al). Listening to music during surgery reduces stress and anxiety (based both on subjective evaluation by the parent and objective parameters like saliva cortisol levels, heart rate and blood pressure). Stress levels continued to be lower two hours after the surgery. (RCT by Handan, et al; RCT by Hepp, et al; systematic review by Weingarten, et al; Cochrane review) When people listened to music after the surgery, they reported less pain and used less morphine. (RCT by Ebneshahidi and Mohseni)

Availability and Caregiver Preferences

In a survey of midwives and OB’s in Germany, 97% had the means to play music during vaginal birth, but just 38% of those did routinely. 47% had the ability to play music during a cesarean, but of those, only 15% typically did. 66% would recommend music during vaginal birth, and 38% during a cesarean. Most professionals felt music was helpful for team communication and patient communication, was relaxing to them and did not report that music distracted the medical team.

It may be worth educating parents that their caregivers might not think to suggest that they use music during labor or might not offer to play music during a cesarean, but that the parents can play music, or ask for it to be played in the OR, and generally that would be supported.

Types of Music

All of the above research is based on simply listening to music. The study protocols ranged a bit on whether the participant listened to music on headphones or in the room, and on the type of music played. Some used instrumental recordings only, some used songs with vocals. In some cases, there was standard music played for all, in some the participants were able to choose amongst a few standardized selections, perhaps in different genres to appeal to different tastes. Some used music associated with cultural traditions or “relaxing” music with no major changes in dynamics. In other cases, the person in labor chose the music.

I have always encouraged parents to think about having two kinds of playlists – one that motivates them to get up and moving which can be helpful when you’re getting tired but know that movement and positioning is helpful and one that relaxes them and make them feel safe and comforted.

Where to Cover

Here are ideas for where to include this info in a prenatal class:

  • When talking about stress reduction in pregnancy, touch on the benefits of music for reducing anxiety and improving baby’s heart rate.
  • When talking about exercise, talk about creating a get-up-and-get-moving playlist that you can use for exercise during pregnancy and then use in labor if desired.
  • When teaching relaxation exercises, talk about creating a soothing playlist to use during pregnancy to calm you and build positive associations, then use it again in labor.
  • When talking about what to pack for the hospital, remind them to prepare their playlist.
  • When talking about getting settled into the hospital or birth center after triage, remind them to turn on their music to create the environment they will best labor in.
  • When I teach the 3R’s of Labor Coping (Relaxation, Rhythm and Ritual) I always say “if you turn on music and the person in labor relaxes, then keep it on! If you turn it on and she tenses, turn it off for that contraction, then between contractions, try to figure out if all music is bad, or just that particular music (or volume or whatever), then correct it.
  • When teaching how to have the “best possible cesarean” if it comes to that, include asking for music to be played.

Photo credit: from, marked in google search as free to share and use

How much does it cost to formula feed for one year?

infant formula on store shelves

TLDR: the short answer is that in 2023, it costs approximately $2500 per year if you’re feeding your baby a basic powdered formula. For ready-to eat, it’s about $3300. If you need hypoallergenic or other specialty formulas, it could be $5000+.

To calculate the cost of a particular brand of formula:

For ready to feed: Take the cost of the container, divide it by the number of ounces in the container. That’s how much it will cost for each ounce baby drinks. Now multiply that times 10,000 for the number of ounces baby will drink in a year.

For powdered: Take the number of ounces of powder in the container and multiply it by 6.5 ounces, because one ounce of powdered formula makes 6.5 ounces for the baby to drink. Now, take the cost of the container and divide it by that number of ounces of drinkable formula you can make. That’s the cost per ounce. Multiply by 10,000 ounces for a year’s worth.

All the details behind that summary:

If you want more insight into my estimates, read on. If you just want to know how to save money on formula, scroll to the bottom of this post.

I thought this answer would be trivial to look up. I did a Bing search for “how much does it cost to formula feed a baby for a year?” Here are answers from the top results in a Bing search.

  • $1642 on average, based on calculator: KellyMom (from 2016)
  • “Families who follow optimal breastfeeding practices can save between $1,200–$1,500 in expenditures on infant formula in the first year alone” – US Surgeon General (document from 2011)
  • Parents in 2021 said $1000 – 2000 a year, citing that Surgeon General statement.
  • Baby Center cost calculator: implies $183 per month [equivalent of $2196 per year). But on another page on Baby Center from 2022: ” $400 to $800 is the average monthly cost” [that’s $4800 + a year)
  • One of the top Bing search results is this page from Breastfeeding Center of Ann Arbor, that says the cost of formula feeding is “Between $1,138.5 and $1,188.00” but that assumes formula is 7 to 14 cents an ounce, so I’m not sure when it’s from.
  • Pricer says “Four cans are what an average baby would consume in a month, this costing around $55.” [annual equivalent: $660.)
  • Romper has a 2018 article someone’s actual spending of $1942 for one year.
  • And Smart Asset’s very confusing article says $821 – 2920 depending on the brand you use, then two lines below that shows calculations of $4927 – 10,493.

If we put together all these answers from the top several results of a Bing search, you learn that formula will cost somewhere between $660 – 10,400 for the first year. Not very helpful, right?

So, I decided to do the math myself. It’s harder than you’d think…

How many ounces of formula does a baby consume in a year?

The standard rule of thumb is that a baby 0 – 6 months who is eating only formula should consume 2 – 2.5 ounces per day per pound that they weigh. (So a larger 4 month old baby is eating more than the smaller 2 month old was, obviously.) As you add in solid foods, formula is still their biggest source of nutrition, but they’re also getting some calories from solids, so the daily formula consumption actually goes down a little from 6 – 12 months.

I could have looked up how much an average baby weighs at each month, and how much that meant they would eat each day that month, but that would be a lot of work, I used Kelly Bonyata’s estimates of how much formula babies need per day – they seemed reasonable. So, first month at 21 ounces a day, second month at 26.5, next four months averaging 32 ounces a day, then 3 months at 28 ounces, then 3 months at 25 ounces a day. That totals up to 10,035 ounces per year. (We’ll ignore for now that you probably spilled some and certainly had to dump some when your baby didn’t finish a bottle.)

How much does formula cost per ounce?

So, you can’t just look at the per ounce cost that shows on the store shelf or online comparisons. Powder will always look like it’s more expensive per ounce then ready-to-drink, but it’s not really!

Forbes magazine made this mistake in their article on the best formulas. They say Similac Pro-Total Comfort Infant Formula “is the most cost-effective formula on our list.” It lists it as 30 cents per ounce. To feed a baby for one day, you’d need 25 ounces of that ready-to-feed product, so that’s about $7.50 for one day. Just below that, Forbes lists Gerber Good Start Gentle Pro, which it lists as $1.48 per ounce, which to Forbes’ apparently uneducated eye looks more expensive than the Similac. But that one ounce of powder makes 6.5 ounces of liquid formula for baby to drink once you add water. So for one day, you’d need 3.8 ounces of powdered formula, which would cost $5.69 for a day’s worth of formula. Much more cost effective.

How many ounces of powdered formula make one ounce of formula for baby to drink?

If you’re curious about the math that got me to 1 ounce of powder = 6.5 ounces of mixed formula, here it is: If you’re buying powdered formula, using this container as our example, there’s 20 ounces of powder (that’s a weight measurement) which is equal to 566 grams. It says that for two ounces of water (a volume measurement), you add 8.7 grams of powder. (note: this actually makes slightly more than two ounces of formula for baby to drink… that’s a math error we’ll ignore to make up for that spilled and wasted bits we mentioned before…) So, in a 20 ounce / 566 gram can, you have enough to make 65 2-ounce bottles, which is 130 ounces that baby can drink. So every ounce of powdered formula makes ~6.5 ounces of formula for baby to drink. Or the way Joshua Bartlett does the math, “you end up using 0.3 oz of your formula to make about 2 fluid ounces of formula.” In that linked article, he also has helpful calculations for parents about how many servings are in a can of formula / aka how long will a container of formula last.

Per ounce costs of recommended brands:

I looked at what brands are recommended by Forbes and Baby Center. (Note: I’m not saying I recommend these brands particularly – I’m just using recommendations that the average parent would find online.) I priced some of those on Amazon* for sake of getting a basic estimate.

All purpose powdered formulas:

Gerber Good Start Gentle Pro. $30.49 for 20 ounces of powder which would make 130 ounces of drinkable formula, so 23 cents per ounce of drinkable formula. The 10,000 ounces a baby would drink in a year cost $2345.

Enfamil Neuro Pro. $52.49 for 31 ounces of powder which would make 201.5 ounces, so 26 cents per ounce, or $2611 for a year.

All purpose ready-to feed: Similac Total. $62.69 for 6 32 ounce containers. Amazon thinks it’s $1.96 an ounce, but that’s wrong. Because the price is for 6 32 ounce containers not just one, that’s 192 ounces, so it’s 32 cents per ounce, or $3,265 per year.

Hypoallergenic ready-to-feed: Similac Alimentum $12.79 for 32 ounces. 39 cents per ounce. $3996 for one year.

Hypoallergenic powder: Neocate Syneo Infant $51 for 14.1 ounces of powder, which would make 91.7 ounces of drinkable, so 55 cents an ounce, or $5561 per year.

So, that leads to my best estimate that to formula feed a baby for one year would cost $2500 – 5000.

How can you reduce the cost of infant formula:

  • Choose generic store brands over the brand names that spend a lot on marketing. All formulas have to meet the same FDA standards.
  • Buy powder, not ready-to-eat. Only buy hypoallergenic or other pricey formulas if your doctor says that it is necessary.
  • Be a smart shopper: by shopping around to different stores, buying on sale, clipping coupons, or getting bulk or subscription discounts you can reduce these costs.
  • if you are a low income parent, you may qualify for WIC (Women, Infants and Children program) or SNAP (often called food stamps) to help with the cost of formula feeding. Check to see if you’re eligible for WIC. Check if you’re eligible for SNAP. Local food banks or other programs may also have resources for you if you can’t afford formula.
  • If you are planning ahead and have not yet had your baby: perhaps consider breastfeeding? Breastfeeding is basically free – the lactating parent may just need to add a few extra calories to her diet to support milk production plus vitamin D supplements for baby. If you’re wondering whether breastfeeding is right for you, take a class or read about it (we cover it well in a book I co-author) just to see whether you think it’s a possibility for you.
    • If you already had your baby but you aren’t currently breastfeeding, it can be possible to induce lactation – check out these articles: Inducing lactation – even if you never breastfed, or relactation if you have breastfed in the past, even for a short time.)

One key: never try to save costs by diluting formula with extra water! Your baby will not get the nutrients they need and their growth and development may suffer. Also, do not use homemade formula recipes you find online – most are nutritionally inadequate and some are actively harmful.

Learn more

*Note: the links to the formula brands above are Amazon affiliate links. If you click on those and then purchase anything on Amazon, I do receive a small referral bonus which supports this blog.

Breastfeeding Class Curriculum

I created a PowerPoint for a 2 hour long breastfeeding class that reflects all the current research-based lactation advice. I have included recommendations for breastfeeding video clips to use. (And here’s info on how to download them and embed videos in your PowerPoint.)

You can download this and use it in your classes. Hope it’s helpful! (To download it, go to the menu button in the bottom right corner of the slideshow image, click on the down button and choose download. You can then save that copy to your own computer and edit however you choose.)

Here’s a PDF of just the slides, if that is helpful. It doesn’t include the notes with more details on what to say about each slide.

Changes in Lactation Advice

If, like me, you’ve been teaching birth education for many years, it’s important to keep up on how advice changes or evolves as new information is learned. There have been huge shifts in lactation advice over the past 10 or so years, so I will summarize those here to the best of my understanding. I am not a lactation consultant and never have been, so IBCLC folks, please let me know if I’ve got anything wrong or am mis-interpreting the data.

I have created a PowerPoint curriculum for a breastfeeding class that you can download, which reflects this updated advice.

Antenatal Milk Expression

We once advised parents against a lot of nipple stimulation during pregnancy, concerned that it might start labor. That’s changed. It is now reasonable to recommend hand expressing colostrum started at week 36 of pregnancy unless care provider considers someone high risk for preterm labor. It can help milk volume increase sooner after birth. Those who might want to express: people with diabetes (any type), PCOS, high blood pressure, obesity, breast hypoplasia, history of low supply or previous breast surgeries. It may also be helpful if they are expecting multiples, or a baby with a cleft lip, palate, IUGR, Down Syndrome or other complications that might lead to them needing special care after birth and increase the chance that formula or supplemental feeding would be recommended. It can also be helpful for any expectant parent to help them feel more confident about breastfeeding.

I also do feel that overall, we are seeing more attention on hand expression than in the past. There are helpful videos showing how to do hand expression at:  and

Learn more:

Laid Back Position

When I first trained 20+ years ago, we were teaching cradle, cross-cradle, football and side-lying positions. About 10 years ago, I started hearing more about sitting up / straddle hold and more about the laid-back position. (Laid-back is a semi-reclined position, like resting on a deck chair by the pool.) Now, most research and practice seems to be leaning toward this (combined with infant-led latch) as the best option.

Colson describes the Biological Nurturing approach: “Mothers lean back and place the baby on top so that every part of the baby’s body is facing, touching, and closely applied to one of the mother’s curves… Nursing in a laid-back position… promotes neonatal locomotion by releasing up to 20 primitive neonatal reflexes which act as breastfeeding stimulants. BN is quick and easy to do; there is no lining up of body parts and no “correct” breastfeeding procedures…” Note: in this position, the parent does not support her breast, and gravity holds baby in place, so it can free up one or both hands.

You can find videos with more information about how to use the laid-back position and baby led latch at Laid-Back Breastfeeding: and

This approach significantly reduces cracked and sore nipples. (Milinco, Wang.)

Learn more:

Baby-Led Latch / Symmetry?

There is also an increased emphasis on letting the baby take the lead in latching on. This increases duration of exclusive breastfeeding, decreases nipple pain. (Baby-Led Latch: Caixin Yin, et al. “Effect of Baby-Led Self-Attachment Breastfeeding Technique in the Postpartum on Breastfeeding Rates,” Breastfeeding Medicine, 16:9. (2021) This video illustrates an infant led latch.

There is a lot less talk about the old method (using U-holds and C-holds to shape the breast like a sandwich before latching, tickling baby’s lip till mouth is open wide, then rapid arm movement to get them to latch on). It’s more about just bringing baby’s nose near the nipple, touching the nose or upper lip with the nipple so the baby tilts up, opening mouth wide and taking a big mouthful of nipple.

Jack Newman describes the ideal latch as asymmetrical, where more areola is covered by the bottom lip than the top, and where the chin indents the breast, but the nose never quite touches the breast. (When Baby is Latching Well: Jack Newman and the International Breastfeeding Center. “Latching and Feeding Management”, 2021.

Conversely, Pamela Douglas has a very different view based on her reading of ultrasound images of latch. She prioritizes a symmetrical face-bury, where the nose is against the breast. She also says there should be no visible lips, because if you can see lips, there is drag on the nipple which causes pain. (This idea of neutral lips is different than the flanged / “fish lips” I was once taught.) She has a video at that highlights her concept of gestalt breastfeeding. (Pamela Douglas, “A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding,” BMC Pregnancy Childbirth, 22:94. (2022) see additional file 1 in that article for details on gestalt method.)

Nipple Soreness

Of course, a good position and good latch continue to be key to reducing nipple soreness. Where I used to see recommendations that if the latch isn’t good, you should break suction and try again, more recommendations now say that most latch issues can be fixed by: tucking baby in closer to the parent so there’s no gap between them and making sure baby is aligned (ears, shoulders and hips in a line.) “Adjust the body, adjust the breast, adjust the baby” – microadjustments in each can fix the latch.

Yeast Infection?

Some breastfeeding parents with persistent nipple pain during and between feeds also may have shiny pink nipples with white flakes of skin. In the past, this was often diagnosed as a yeast infection and treated with antifungal medications. But there’s no evidence that candida causes the nipple pain, and antifungal treatments are no more effective at treating it than doing nothing.


In the past, I have been told to recommend lanolin, hydrogel dressings and other moist wound healing approaches. Current research indicates that hydrogel, lanolin, antifungal creams, Vaseline, expressed breast milk and all-purpose nipple ointment are no more effective at reducing nipple pain than it is to do no treatment at all, and some may actually delay healing due to moisture related damage.

Most nipple pain reduces to mild levels by 7 to 10 days postpartum no matter what you do or don’t do.

Anatomy / Engorgement / Mastitis

We have a new understanding of breast anatomy based on ultrasound imaging vs. cadaver study as past models were based on. A summary is here: “Anatomy of the Lactating Breast,” Medela. And the research: D. T. Ramsay et al., “Anatomy of the Lactating Human Breast Redefined with Ultrasound Imaging,” Journal of Anatomy 206, no. 6 (2005): 525–34.

Here is an image from the Ramsay article with an artist’s impression of breast anatomy – note how this differs from older illustrations showing “bunches of grapes” in the alveoli and lactiferous reservoirs.

breast anatomy illustration

We have learned there are not sinuses / reservoirs that store milk in the breast. Only about 1 – 10 ml can be expressed before a let-down. So, getting a good latch so you get a good letdown is essential.

Plugged Ducts?

We used to teach about plugged ducts, saying that milk was clogging a duct, and we had all sorts of advice for placing baby’s mouth so it lined up with the lump, and massaging as the baby nursed, or using a vibrating device like an electric toothbrush to relieve that. Based on new learnings about breast anatomy, clogged ducts are not actually possible. “Ducts in the breast are innumerable and interlacing and it is not physiologically or anatomically possible for a single duct to become obstructed with a macroscopic milk ‘‘plug.’” (Mitchell, et al) And deep tissue massage to relieve a clogged duct can worsen edema, inflammation and pain.

Parents should be taught that slightly lumpy breasts are normal, and that localized inflammation is just that, and can be treated similar to how we treat engorgement.


For engorgement, ice and ibuprofen to reduce pain and inflammation are recommended. Cabbage leaves are no more effective than ice. Heat (e.g. warm compresses and showers) may provide comfort but can also worsen symptoms. If using hand expression or pumping to treat engorgement, express only enough milk for comfort and/or to help baby latch on. Over-pumping can worsen engorgement.


If the symptoms are pain, redness and a short-duration fever, that is considered inflammatory mastitis, and likely not an infection. It can resolve on its own with continued breastfeeding, rest and plenty of fluids.

If the fever, pain and inflammation continue for more than 24 hours, it could be bacterial mastitis, an infection. They should check with a lactation consultant or care provider – antibiotics may be recommended at that point.

To learn more about all the topics in this section, read: Katrina Mitchell, et al, “Academy of Breastfeeding Medicine Clinical Protocol #36, The Mastitis Spectrum,” Breastfeeding Medicine, 17:5. (2022)

Paced Bottle Feeding

When giving a bottle to any baby, but especially one who is primarily breast-fed, we can use a method called Paced Bottle Feeding. Many parents hold the baby horizontal on their back and the bottle vertical, so the nipple is filled with milk. Baby takes in a lot of milk really fast this way, which might seem efficient, but can lead to over-feeding or increased spit up. It also teaches a baby to expect this fast flow and “flow preference” might be the true “nipple confusion” as baby gets used to fast flow. With paced bottle feeding, instead we hold the baby vertical and the bottle horizontal so they’re taking milk in more slowly. When they pause a bit in sucking (as they would at a breast), you can tilt the bottle completely horizontal to give a rest. When they resume sucking, you tilt it up just a bit so they get more milk. Check out these videos: and


If you have comments on anything you read here – about any surprises you see, or any misinterpretations you want to clarify, please comment below!

AV Aids – Breastfeeding Videos

Here are a collection of helpful videos to use in class or 1:1. Note: I always download any videos I want to use in class, because I don’t trust that the internet connection will always be perfect at the moment I want to use it. To learn how, read “Incorporating Video into PowerPoint.”

For each video, I captured a still image to help give you a sense of what it looks like. In each section, they are in order from clips I think would be most helpful for educators to least. FYI, I have also created a PowerPoint curriculum for a breastfeeding class which includes recommendations for which videos to link to and what clips to use.

Laid-Back Position, Baby-Led Latch

baby latched on

Baby-led attachment (laid back position) : 7:39 video overview from Australia. You might use just the segment from 2:30 – 4:20 that shows the process. Also at

baby resting on parents chest laid back position

Laid-Back Breastfeeding – 2:38. starts with 30 second still image of laidback position: also at

twins latched on

A 53 second video showing baby-led latch in laidback, from Australia. Includes b brief image of nursing twins.

newborn baby about to latch

A 21 second video that shows breast crawl – baby-led attachment in a laidback position (resolution not great…)


effective latch

How to check if baby is latched well. 1:44 from the UK. I would use :20 – 1:20 clip. Also at

Attaching Your Baby at the Breast – from Global Health Media. Nice hunger cues at 3:09 – 3:40 (great lanugo too). Nice latch at 5:17 – 5:47 though I wish she laid-back instead of being so upright.

animation of an effective latch

Animation of an effective latch: A similar (but different narration) video is at

effective latch

Jack Newman’s International Breastfeeding Centre site has several helpful videos, including “Baby 28 hours old assisted latching.” The video resolution isn’t great on that one, but really nice view of suckling in action. “Good Drinking” is also quite good.

baby latched on

No narration – just a view of a nice latch and good suckling:

Additional Positions for Breastfeeding

parent nursing in the football hold position

Several positions: 9:26 From Global Health Media – shows diverse parents in developing countries. Also at

Hand Expression

hand expression

This full video is 7:33, but I would use just the 2:09 – 4:15 section of it. With massage, I would emphasize this is gentle, not firm massage – firm massage can cause inflammation. (I’ve heard it described as “gentle… like petting a cat.”) or at

teaching hand expression

Hand expression from Unicef UK. Shows specifically how to teach expression using a breast model. Also at

hand expression

“Basics of Breast Massage and Hand Expression”. I would use 1:03 – 2:48. Note: she has her hand right at the nipple vs. the inch or so back from the areola shown in the video above.


If you don’t teach breastfeeding during your class, but want to share a link with students to get that info on their own, these are all good comprehensive resources. There are also good clips from each I could use in a class.

baby during breast crawl

Breastfeeding in the First Hour: An 11:49 overview of getting breastfeeding off to a great start.

lactation consultant teaching breastfeeding

First Droplets has a 15 minute overview of Breastfeeding in the First Hour. (or They also have great short videos on specific topics like latch:

Nancy Morhbacher has a 30 minute long video on Natural Breastfeeding (laid-back, baby-led latch). Also available in Spanish.

Paced Bottle Feeding

This method can be used by anyone who bottle feeds. It is especially helpful for breastfeeding parents to help avoid “nipple confusion” which may be primarily “milk flow preference” – where if babies get used to a really fast bottle feed they may be reluctant to return to slow breast milk flow. This process slows it down to mimic breastfeeding.

baby sucking on bottle that is held almost horizontal

You could just use the clip from :29 – 1:49.

parent holding baby with bottle held almost horizontal

And in this one, I would use 1:43 – 3:03.

More Resources

For Parents: In my podcast, there is an overview on how to breastfeed your baby. At that link, you can listen to it, or read the transcript.

For Professionals: A lot has changed in lactation advice over the past ten years. Find a lactation update here.

Incorporating Video into PowerPoint

I know many educators use videos from YouTube or elsewhere on the internet during classes. I always want to have my videos downloaded so that I don’t have to count on the internet working when I want to show the video. I also like to trim them to show exactly the clip that I want my students to see. Here’s how to set up a PowerPoint so all your videos are ready to go.

Downloading what you need

If you want to download videos from YouTube or elsewhere on the internet, YTD downloader is a free software program that enables you to do that easily. (You could also check out 4K Video Downloader as an option.) Please be aware of copyright law and consider whether you are legally able to use that content for your purposes.

Gathering Recordings in one place

Make  sure that you have saved all the video you will use in a presentation IN THE SAME FOLDER as where you’ve saved the presentation.  We will only put a LINK to the video in the slide deck. If we insert the whole video in the slide deck, the PowerPoint becomes a massive file and has problems loading. Having the video in the same folder makes it more likely the link to the video will work as you intend.

If you’ll upload your work to google drive for someone else to use, make sure that when you upload the PowerPoint, you also upload all the videos  to the SAME FOLDER as the presentation they’re associated with and that they know they’ll need to access both the slide deck and the videos for the presentation.

Inserting video recordings – .mp4, .mov

Go to the slide where you want the video, then choose the insert menu, then choose “insert media” (on the right hand side of the screen) then choose video, then choose video on my PC. Find the file you want, select it, and then in the bottom right where it says “insert”, click on that little triangle to get the drop-down menu. Choose “insert link to file” instead of “insert” video. This will help keep your PowerPoint a manageable size – if you insert the whole video, the PowerPoint is huge, and that can cause problems with it running smoothly or being easy to upload.

Now click on the video image on the slide, and the playback menu will appear at the top. In the playback menu, choose “start automatically”. Set the volume to medium. (You’ll absolutely want to test the volume later to see how it sounds to your meeting participants, especially if you’ll use it on Zoom. Sometimes what sounds quiet to you will blast them.)

You’ll often want to choose “play full screen” but not always (like if you want to type lyrics on the slide to appear with the video of a song) and you may want to “hide while not playing” – that’s up to you.

If you want to show just a portion of the video, then click on “trim”. It will let you choose to start exactly where you want them to start, and end where you want to end.

When you’re done, run through the slide show to make sure it performs as you expect it to. I usually insert a slide before the video that has an image from the video and properly credits it. This gives me a chance to set up the video – what will we see, what should you pay particular attention to, why am I showing it. Then, when I’m ready I advance to the next slide and the video begins.

AV Aids for Birth Classes – Videos

Videos are such a powerful tool in a childbirth and parenting preparation series. Seeing someone in labor can help to prepare them for what that might look like and feel like. Seeing a birth in a hospital setting (or at home if you’re teaching a home birth class) can help them start to imagine what their birth will be like and also gives them an opportunity to see maternity care procedures. Seeing a newborn baby squirming around helps them grasp what their baby might be like at birth. And seeing a baby and a breast come together is essential preparation for breastfeeding.

So, where can you find great videos? Here’s a collection of what I know about. PLEASE add comments with more details on these resources or with recommendations for other videos you would use in class.

Other than Injoy, almost all of the videos listed are free of charge. I put a $ sign at the end of the listing if you have to purchase them.


If you can afford them, I think that nothing beats Injoy videos. Learn about their videos, and preview clips at Consistently high quality, fairly diverse families featured. They intersperse clips from births with animated graphics of things such as the descent of the fetus during birth, and offer clear, easily understood narration about the birth process, breastfeeding, or newborn care. Childbirth educators who only work with clients planning out-of-hospital births may feel they are too medicalized, but if most of your population is planning a hospital birth, I think they appropriately balance working toward a lower intervention birth while also learning key information about interventions. $$

Other Options I have used:

Mothers’ Advocate. This series was jointly produced by Injoy and Lamaze and covers Lamaze’s 6 Healthy Birth Practices. All the benefits of an Injoy video, but free of charge. They are from 2010.

I made a video about newborn cues. You can learn more about it in this post.

Other Recommendations:

All the videos from here down were recommended by other birth educators for use in classes. If the person who recommended the video gave details about what they liked, I included those notes. I have not watched them all myself so please review in detail yourself before using in a class!

Birth Info

Evidence Based Birth by Rebecca Dekker, phD – her blog is great but I have not yet watched these videos, which include a full birth class series called “Birthing in the Time of COVID”.

Mandy Irby Birth Nurse – includes a multi-video series called Online Lamaze Class:

Alice Turner, doula and birth educator. Lots of videos with tips on comfort techniques and more.

Gentle Cesarean from Brigham and Women’s Hospital:

Beaumont Hospital has a full series of videos:

Hello Baby from the Childbirth Media Center: These are good, but they are really OLD – we had them when I started teaching 25 years ago. (To all the old educators out there… these are the Carl and Donna videos.)

For talking about pushing and a way to practice it more concretely when an urge is obviously not present.

Cesarean video – from Australia, so note any differences between what’s shown and your local practice:

Playdough Surgery – cesarean. There’s information here on using it in birth classes.

Birth Stories

Examples of what real labor looks like:

Alice Turner, Lamaze educator, recommends 5 birth videos with info on why she likes each video – find her recommendations and links to those videos at:

Birth of Easton:

Birth of Sloane – the person who recommended this said: “Home birth – Great partner support and example of different positions – no nudity – 6 mins 31 seconds – good sounds – baby born in water – interesting example of cord cutting by burning.”

Blake Andrew Isom. “Shows how the partner was right where the mother wanted him to be. He gave words of affirmation but you don’t hear them in the video. She had a doula at her birth so the husband was able to stay right with the mom holding her hands and comforting her.”

Denver Birth Videos. The person who recommended them said “I found this birth videographer from Colorado. She had so many beautiful videos on her website that demonstrated so many coping techniques and different things to try even in early labor like walking up stairs etc. Lots of great partner support and she has a huge range of types of births (home birth, water birth, land birth, hospital birth etc.). I personally messaged her and asked if I could use her videos in my classes and she gave me permission.”

Compilation of scenes from many births:


Great video with a Black dad talking about ways to support a postpartum parent:

For talking about helpers vs visitors. FUNNY! Some may not love it because it pokes fun at some worthwhile breastfeeding advice but I preface it and it lightens the mood as a good transition after talking about some of the hard stuff during postpartum.

Viral a couple years ago, but the Frida mom commercial is wonderful to open a discussion of postpartum.

Safe Infant Sleep for Grandparents:

Breastfeeding / Chestfeeding

Please find those video recommendations here:

    Important Considerations

    When choosing videos, here are some things to think about or watch out for:


    ALWAYS “set up” the video. Tell them

    • what they’re going to see
    • why you’re showing this video
    • what they should look out for

    For example, here’s part of how I set up the Injoy Stages of Labor video: “I always show this video in the first week of class, because it provides a full overview of the labor and birth process from start to finish – sort of a preview of everything we will cover during this class series. You’ll see clips from three or four different families giving birth in a hospital, so you’ll see typical hospital procedures as well. I do want to give you a heads up: you will see a vaginal delivery of a baby – if you are uncomfortable with watching that, you can always close your eyes or turn away – but we find for many people it’s easier to see this for the first time when it’s not you or your partner giving birth… What I really like about this video is you’ll have a great opportunity to see what people in labor may look or sound like, what their partners can do to support them in labor, and how the care providers also support them. I want you all to look for some ideas on what each person does to help work with and manage labor pain.”


    ALWAYS allow a few minutes to debrief the video. I kind of putter around a bit when turning off the video, turning the lights back on, sitting back down to give them just a moment to gather themselves. (It’s not unusual for someone to get a little weepy during a video.) Then I say “So, what did you see that surprised you? What do you have questions about?” Usually one of them will respond. If not, I may say something that addresses something that I think may worry someone, like “you may have noticed birthing people who weren’t wearing many clothes during labor… I want you to know that is because they chose to take them off, not because it’s typically required.” Then I’ll ask them to share things about whatever I asked them to look for in the video.

    Diverse characters / settings:

    Think about the students in your classes – age, race, socioeconomics, visions for ideal births, settings in which they will give birth. Make sure that there are people in the video who look like your students and/or have similar life experiences so they can relate, and they will feel like they belong in your classroom. If the people or settings shown are not like your students, give information about why this video was chosen. If you share a birth story video that focuses on one labor from start to finish, that may not feature a family who looks like theirs, so I introduce it by saying something like “this particular video has a single parent who is supported by her mother and doula – but all the support techniques can be done by any support person” or “this person does not speak English, so they have an interpreter at their birth. I like how the video shows all the stages of her labor from start to finish, so we can see how that process unfolds for one particular person. It shows how families might need to change and adapt their birth plan as things unfold differently than planned.”


    I typically teach a 6 week series. I try to include some video in each session. I sometimes time it for right before a break so we can watch it, debrief it, then I send them off to break, where they might choose to talk it through with a partner or other students. Sometimes I show it right after break to get their brains back into class mode. I personally like videos that are about 8 – 13 minutes long… long enough to be worth settling in for, but not much longer than that because they eat too much into my class time. Some instructors take the flipped classroom approach and have students watch the videos between classes and discuss in class.

    Prepping Videos for Use in Class.

    I like to download my videos in advance, insert links to them in my PowerPoint and trim them to exactly the part of the clip I want to use. Learn how to incorporate video in PowerPoint.

    Be sure to also check out my posts on:

    AV Aids for Birth Classes – 3-D Models (dolls, pelvises, breasts, and more…)

    AV Aids for Birth Classes – Posters and Images (to put on the wall or into a PowerPoint

    A New PMAD Handout

    When we last revised Pregnancy, Childbirth and the Newborn, I struggled with including the list of all the risk factors for PMAD. It’s important information to have, and yet, I worry about someone who has a lot of those factors reading through it and getting more and more discouraged, and worried that there was no way they could avoid PMAD given their complex history. I wanted to find an approach that could empower rather than defeat.

    Yesterday, I played around with a lot of metaphors…

    • a seesaw where the more risk factors you have, the more protective factors you need to balance them out
    • a budget metaphor
    • a fill the bucket metaphor where the risk factors drain the bucket
    • a floating object metaphor… if you have a lot weighing you down, you need a lot to buoy you up so you don’t feel like you’re drowning

    Finally I found a metaphor I liked… I created a handout where I try out the baggage metaphor…. if you know you have a lot to carry, then you can plan ahead (pack it well), build your strength (by learning coping skills), get a luggage cart (learn about resources) and ask for help to carry it.

    Here’s the free printable handout, feel free to use it any time, anywhere.

    I also updated two other handouts: One on what you really need to buy for babies, and one on planning with your parenting partners how you’ll divide up responsibilities after the baby is born.

    Newborn Cues Video

    The TL; DR: Expectant parents often wonder how they’ll know what their babies need, and new parents often wonder why their baby is crying and what they could do to figure out their needs before they cry. Newborn cues are instinctive behaviors that babies display which help us to figure out what they need. This YouTube video (which you are welcome to share in classes or in one-on-one appointments, or link to from your website) provides an overview of newborn cues. (Here’s a link you can share:

    The Story Behind the Video

    As a first-time parent back in 1993, I was clueless.. it seemed like my baby would go from 0 to 60 from happy to miserable in a moment. Years later, I watched videos of his early days, and saw that he was giving SO MANY cues about his needs that I missed until he escalated to screaming. So, when I started teaching newborn care classes in ’99, I always incorporated information about newborn cues.

    Back in 2010, I put together some YouTube clips as a “Name that Cue” activity to use in my classes. I put it on YouTube for my ease, and in case anyone else would find it helpful. Now that video, and excerpts from it and updates of it have been viewed over 2 million times!

    The video linked above is the newest version, where I’ve incorporated feedback I’ve gotten on previous versions and added a couple more clips. I’ve also set it up so it will be easy to create translations of it into other languages, and I’m currently recruiting educators whose native language is something other than English to help me create translations. (contact me at janelled at if you’re interested in helping!)

    No Narration Option for Classes

    For birth educators or others who are using this video in an educational setting: That video is designed to be watched independent of a class or educator. It’s 20 minutes, which is a lot of time for a class. If you prefer, I have a 13 minute version here with no narration that you can show and talk through it with your students.

    Video Segments – Cue by Cue

    In 2014, I created segments that covered only one set of cues at a time. Here’s links to those, if you prefer them.

    Teaching about Cues

    In my podcast episode on Caring for Your Newborn, you can see how I integrate teaching about cues into the information I give on newborn care and feeding.