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.
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.
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.
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.
Zhi Wang, et al, “The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis,” BMC Pregnancy Childbirth, 21(1): 248. (2021) https://pubmed.ncbi.nlm.nih.gov/33761882/
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) https://pubmed.ncbi.nlm.nih.gov/33913745/). This video illustrates an infant led latch. https://www.breastfeeding.asn.au/resources/baby-led-attachment
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. https://ibconline.ca/information-sheets/latching-and-feeding/)
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 https://possumsonline.com/video/how-babies-breastfeed 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) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8808964/ 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.
Ryan Colton Betts, et al. “It’s Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain,” Breastfeeding Medicine, 16:4. (2021) https://pubmed.ncbi.nlm.nih.gov/33305975/
Ointments?
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.
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.
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.
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.
Mastitis
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) https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf
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: https://www.youtube.com/watch?v=OGPm5SpLxXY and https://www.youtube.com/watch?v=TuZXD1hIW8Q.
Comments
If you have comments on anything you read here – about any surprises you see, or any misinterpretations you want to clarify, please comment below!
Offers a brief overview of key information about caring for a newborn – how to figure out what baby needs by observing their cues, how to meet those needs with feeding, diapering, dressing, and bathing, calming crying, and helping your baby to sleep well.
This episode covers second stage labor – the birth of a baby, third stage – the delivery of the placenta, and the first hour of baby’s life. Addresses when to push, how to push, and positions to aid labor progress. Talks about “the Golden Hour” of bonding with a new baby. [A full transcription of this episode is available at: https://transitiontoparenthood.wordpress.com/for-parents/labor-and-birth/birth-and-babys-first-hour/]
The 2016 edition of Simple Guide to Having a Baby has gone to print, and will be available to the public at the end of July. (We’re hoping to have copies for sale at the DONA conference in Bellevue, WA) It will be available from Amazon, Barnes and Noble, Walmart, and probably Target.
Simple Guide covers essential information about pre-conception, pregnancy, birth, breastfeeding and newborn care at a 6th grade reading level, in a short, accessible format. It is written by the authors of Pregnancy, Childbirth, and the Newborn. Although we are writing at a different literacy level, we do our best to incorporate the same foundation of current, research-based information and our practical experience of working with thousands of birthing parents over many decades.
What’s new in 2016: increased cultural diversity and sensitivity in photographs and writing, incorporation of the visual aid “The Road Map of Labor“, more links to online resources for more information, and more details on baby care. We have also extensively updated all the medical information. I have an extensive post on all the updates we did to Pregnancy, Childbirth and the Newborn – we weren’t able to incorporate all of these details into Simple Guide, but they certainly did inform our revision of this shorter work.
If you would like to write a review of Simple Guide, I do have galley proofs available. Contact me and jdurham at parenttrust dot org, and tell me about yourself and where you publish reviews, and we can make arrangements to get a proof to you.
Today, I did a presentation on Partner and Family Support for Breastfeeding. Here’s a brief re-cap – and be sure to check out the handout linked from the bottom of the page!!
Research on how Partners and Family Members influence choices about whether to initiate breastfeeding and how long the baby is breastfed
2/3 of women have decided before pregnancy that they plan to breastfeed due to the influence of family, friends, health care providers and the media.
1/3 make the decision during pregnancy, and their strongest influences are: 1) care providers, 2) partners, 3) books and classes, 4) other key friends / family.
A few months down the road when making decisions about how long to breastfeed, their partner, family and friends are much stronger influences than professionals
An expectant parent is more likely to decide to breastfeed and to continue nursing if she believes that key people in her life are supportive of breastfeeding.
The presence of a partner / father increases chance she will initiate BF. But if he then gets very involved in day-to-day baby care, her BF duration can actually go down, because he ends up taking over some of the feeds.
Having an involved grandma sadly reduces the duration of breastfeeding, and can reduce initiation, especially if grandma didn’t breastfeed herself.
However, research shows we can turn this around. If we engage in conversations with partners, and offer written materials targeted at partners and family and classes for them (especially peer led classes) which focus on the importance of breastfeeding, then it is more likely that she will initiate and continue breastfeeding.
If those conversations / classes / materials ALSO include information telling the partner or family member that they play a huge role in her choices about breastfeeding, it is more likely she will initiate and continue.
If those conversations / classes / materials ALSO give concrete ideas to the partner or family member about how to help support the breastfeeding relationship, she will nurse and nurse for even longer.
To read a whole powerpoint on the evidence surrounding influences on breastfeeding (and how we can influence them), click here Influence Of Family On BF Choices.
Teaching Partners and Family Members how to effectively support a nursing parent to increase duration of breastfeeding:
Here are five key areas we can focus on:
Increase Knowledge: Offer relevant, targeted, accessible info about the process of breastfeeding, with an emphasis on how to help with BF and concrete information about how to prevent, recognize, and treat BF challenges.
Enhance Positive Attitude: Teach them all the benefits of BF – for baby, mom, the family, and the world. The more excited they are about breastfeeding, the harder they’ll work to make it happen. Openly and honestly address worries. Encourage family commitment to BF.
Involve Them in Decision Making: Welcome their questions and input. Encourage them to help the breastfeeding parent do research and strategize.
Encourage Practical Support: Teach them all the skills to care for everything baby needs (other than feeding) and to take care of baby’s things (pack diaper bag, do laundry, etc.). Encourage them to take care of the breastfeeding parent (feeding the mom so she can feed the baby), maintain the house (groceries, cleaning, cooking), and manage outside duties (pay bills, plan, make appointments, etc.)
Encourage Emotional Support: Acknowledge partner’s emotional challenges. Encourage them to offer the breastfeeding parent their presence, appreciation, encouragement, affection.
One of the key points in much of the research is that nobody talks to partners about breastfeeding, and that it helps a lot if they are given targeted information that focuses on what the partner needs to know about: benefits of breastfeeding, how it works, how they can help if there are breastfeeding problems and how they can help in general. So, I’ve designed a handout for partners. It is yours to use, free of charge. You can print it, copy and distribute to partners. You can give clients links to it. Anything to help get partners the information they need to be effective supporters of the breastfeeding relationship.
I am a co-author of the book Pregnancy, Childbirth, and the Newborn. (We call it PCN for short.) We have been working on a revision – the 5th edition of PCN will be released in March 2016. You can pre-order it here (affiliate link.)
This post is a summary of all the changes we have made to the book. It is not really meant to be a stand-alone post for someone who is not a birth professional and who hasn’t read PCN. However, if you ARE a birth professional (especially a childbirth educator) and HAVE read PCN, this summarizes what we think are the most important changes in maternity care and birthing culture since 2010 when our last edition came out. I have highlighted with ***asterisks*** the ones that I believe are essential for childbirth educators to be aware of and essential to incorporate these ideas into their classes.
Here you go… all the changes… Note, when I say we’ve “made a change to the website”, that will be upcoming changes to our companion website http://www.pcnguide.com – those will appear live online after March.
Throughout the book:
Gender: Have made the language more inclusive of gender-non-normative families. Have changed many incidences of “pregnant woman” or “women” to “pregnant person” or “people” or “expectant parent.” Where we could, we re-phrased the sentence to avoid pronouns, but when pronouns are needed, we use she or her to refer to the pregnant person. As always, partners are gender neutral, and for babies we alternate male and female by section.
Microbiome: Added a section to the cesarean chapter discussing the microbiome in detail (also added an even more detailed discussion to the website.) Included references to this information in pregnancy complications chapter (when discussing antibiotics for GBS) and in the newborn care chapter when discussing diarrhea and again when discussing colic. See this blog post to learn more
Chapter Order and Division: In this document, I refer to chapters by their chapter number in the old edition. For new edition, the breastfeeding chapter will be divided into two, the pain medication information will be made a separate chapter from Labor Pain and Options, and chapters in the birth section will switch order to:
When and How Labor Begins (chapter 9); What Childbirth is Really Like (formerly chapter 12); Labor Pain and Options (formerly first half of chapter 10); Comfort Techs for Labor (11); Pain Medications (formerly second half of chapter 10), When Childbirth Becomes Complicated (13)
Intro: Added some notes about “how to use the book” that address some of the concerns that Amazon reviewers have expressed about the book. Added a note at the end about gender-inclusive language.
Chapter 1 – You’re Having a Baby: no major changes
Chapter 2 – So Many Choices: Updated health insurance info to reflect Affordable Care Act (see details on health insurance). Included notes about ACOG/SMFM levels of care recommendations, which include birth centers and then define level 1 – 4 hospitals. Also added brief note defining “high risk” pregnancy vs. low risk, saying that a high risk mother should choose a high level of care (OB and level 3 – 4 hospital) vs. a low risk mother can choose anything.
Moved the lists of questions to ask (at a birthplace, of your caregiver, etc.) to website.
Chapter 3 – Common Changes of Pregnancy:
Added a recommendation to subscribe to an email newsletter like Lamaze or Baby Center’s if they want detailed week-to-week information (“this week your baby is as big as a kumquat”)
Made changes to ***how we talk about “the 41st week and beyond”*** given ACOG’s 2014 statement on Preventing the Primary Cesarean, where they recommend that all women be induced at week 41 because of the increasing risk of stillbirth beyond that point and the fact that cesarean rates increase for prolonged pregnancies. We state that some caregivers will recommend that pregnancy continue, with some extra monitoring to ensure that placenta/baby continue to do well, and some will recommend induction at week 41.
Updated section on pregnancy after age 35. (Trivia note: when PCN first came out in early 80’s, average age of mothers having their first births was 22.7, and just under 4% of all births were to women 35 and older. In 2013, the average age at first birth was 25.8. 15% of births were to women 35 and older. 22% of those were the first baby born to the mother.)
Added a section on “If you’re transgender or genderqueer” that gives resources for finding a supportive caregiver and suggests preparing a detailed birth plan to explain things like preferred pronouns and family terms (e.g. pregnant father)
Chapter 4 – Having a Healthy Pregnancy
Added a new section on prenatal screening for birth defects, which includes: first and second trimester blood tests, nuchal translucency screen, second trimester ultrasound, and cell-free fetal DNA testing. Explains that these are all screening tests and none are 100% accurate, so shouldn’t be used as the sole basis for irreversible decisions like termination. If screening tests reveal high risk of birth defects, diagnostic tests (CVS or amniocentesis) are recommended. Although we don’t cover these topics in birth classes, it would be good for all educators to be familiar with the newer testing options. (See my blog for more)
Added signs of prenatal depression to pregnancy warning signs
Added new resource on effects of infections, substances, and environmental hazards: Mother to Baby website, from the Organization of Teratology Information Specialists. http://www.mothertobaby.org/otis-fact-sheets-s13037
Addressed e-cigarettes: Effects on pregnancy has not been studied. MAY be safer because fewer chemicals and no smoke, but still contain nicotine, which is harmful to babies.
Addressed marijuana since some states have legalized recreational marijuana use and several have legalized marijuana for medicinal purposes. (It is still illegal at the federal level and this may come into play in child abuse or neglect rulings in those states.)Some studies show that marijuana use in pregnancy does not increase the risk of birth defects. Others indicate that babies born to mothers who regularly used marijuana had a higher risk of premature birth, low birth weight, small head circumference, and cognitive and attention deficits. These studies were generally done when marijuana use was illegal, and thus difficult to get accurate reporting on. Plus the women who regularly used illegal marijuana were also more likely to use alcohol, tobacco and other drugs, and less likely to access prenatal care, so that may influence these outcomes. Until more research is done, it is wise to avoid recreational marijuana use, and only use it medicinally with the supervision of a caregiver.
Chapter 5 – Feeling good and staying fit: Made changes to ***pelvic floor exercises***, saying there’s not a one-size-fits-all recommendation. Recommend they check strength of pelvic floor muscles (by stopping flow of urine or by tightening around two fingers or partner’s penis.) If they seem weak, then do kegels (note: 10 second kegels are best). On the other hand, these symptoms may suggest the muscles are overly tense: pain in vagina, rectum, tailbone, straining with bowel movements, pain during intercourse, urinary issues such as hesitancy, incomplete emptying or pain. In this case, instead of kegels, she could do pelvic bulging, conscious relaxation, or perineal massage to release tension.
Chapter 6 – Eating Well
Added info on gluten free options
Changed discussion of non-fat dairy items. Research actually shows that people who consume full-fat dairy are less likely to be obese than those who consume non-fat dairy.
Starting with a 2011 medical update of the 2010 edition, we have updated discussion from the Food Pyramid to the new “My Plate” guidelines: http://www.choosemyplate.gov.
Added recommendation for 600 IU per day of vitamin D in pregnancy
Updated miscarriage statistic – it did say 10 – 15%, increased to 15 – 20%. As more women learn about the pregnancy earlier in pregnancy, there has been an increase in recognized miscarriages. Also added a few more details on how a miscarriage is treated (observation, medication, or D&C)
Moved the chart on impact of infections out of the chapter and on to website.
Updated incidence of gestational diabetes. Was 3 – 5%, now 4 – 9%. Included note that in the days prior to (and day of) a glucose challenge test, mother should be well-rested and eat healthy, non-sugary foods to decrease her chance of a false positive.
Updated section on gestational hypertension and preeclampsia. Proteinuria is no longer required for a diagnosis of preeclampsia – if mom has high blood pressure plus either lowered platelets or impaired liver or kidney function that is sufficient. Mild gestational hypertension (BP 140/90) is treated with: reduced activity / stress, daily kick counts, weekly appointments for blood tests and possibly fetal monitoring. ***For those with mild hypertension or preeclampsia, delivery at 37 weeks is recommended.*** For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures. If baby is past 34 weeks, they will deliver baby as soon as she is stabilized. If baby is under 34 weeks, amniocentesis to check for lung maturity and corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable. http://www.slideshare.net/lcmurillo/hypertension-in-pregnancy-acog-2013
Added a very brief section on perinatal mood disorders to point out that depression in pregnancy is quite common (estimates range up to 20%, or 30% in women of low SES.) Amongst parents with postpartum mood disorders, a significant portion (up to a third) say symptoms began during pregnancy. (Interestingly, anxiety and panic attacks decrease during pregnancy due to soothing effects of hormones.) ***This info should be covered in childbirth education classes, and parents can be referred for more information to sources that address PPMD.***
Moved info on breech babies from “When Childbirth is complicated” chapter to here.
Chapter 8 – Planning for Birth and Postpartum
No major changes, except moved “What to pack for the hospital” list from chapter 9 to 8.
Chapter 9 – When and How Labor Begins
Replaced the old Events of Late Pregnancy “arrow” with a new graphic.
Chapter 10 – Labor Pain and Options for Relief
Divided into two chapters: Labor Pain Options and Pain Medications for Labor
In the section on Pain versus Suffering, added in ***the concept of “working with labor pain” ***(see Leap and Newburn. (2010) Working with pain in labour: An overview of evidence. New Digest 2010; 49:22–6.) Also added a brief note about it in the chart comparing pain relief options. If parents believe that comfort techniques are designed to take away their pain, they’ll be disappointed in labor. If they understand that the goal of comfort techniques is to make pain more manageable and help them feel like the pain is something that they can work with rather than something they are suffering through, they may be more satisfied with the experience.
In the last edition, under “Effectiveness of Pain Relief Options” we had cited mother’s experiences from the Listening to Mothers survey. We have kept that, but added info on research into the effectiveness of various methods. In the book, we summarize Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801
Gate control, defined as adding pleasant stimuli to the painful area. Users were less likely to use epidurals or Pitocin and had lower pain scores
***Counter-irritation***, defined as creating pain or discomfort elsewhere on the body (with TENS, ice, birth combs) to cause the release of endorphins. Users less likely to use epidurals, had lower pain scores, and more satisfied with birth.
Central Nervous system control (attention focus, prenatal education, relaxation, hypnosis, continuous labor support). Less likely to use epidurals and Pitocin, less likely to need instrumental delivery or cesarean, higher satisfaction
Most effective is a combination of continuous support with other techniques
Added to website a chart comparing Cochrane summaries on individual non-drug techniques.
See blog at transitiontoparenthood.wordpress.com for more discussion of ‘working with pain’, counter-irritation, and research into the effectiveness of techniques
Chapter 10 B – Pain Medications
In the last edition, we had a chart at the back of the book summarizing all the details about pain medications. That will be moved to the website. pcnguide.com
Added a section on counter-irritation: when the laboring person causes an uncomfortable sensation somewhere to distract her from pain (e.g. bites her lip, digs her fingernails into her palm, pulls her hair). Explained to partners that if this is helpful to her and not harming her, we reinforce it as her ritual. If it might be harmful to her, we substitute – like giving her a washcloth to squeeze in her hands. Addressed birth combs, TENS, sterile water injections as good options
Added peanut balls as a comfort item / item to aid labor progress, particularly in late labor for a mom with an epidural (she lies on her side with the ball between her legs – the pelvic opening gives baby room to descend)
Re-did some of the diagrams of breathing techniques, particularly light breathing – diagram shows fast breaths every second. Re-drawn as a breath every 2 seconds, with a brief pause between each breath. Slide breathing diagram had 5 or 6 exhales per inhale. Should be 3 – 4.
Chapter 12 – What Childbirth is Really Like
In the past, we had described early labor as lasting to 4 cm. ***Shifting to saying early labor lasts till 6***. We describe a “getting into active labor” phase from 4 – 6 cm to acknowledge that labor often intensifies there, and mom needs more support than she did before, but cervical dilation does not really speed up till after 6 cm
Added a sidebar about the 2014 ACOG/SMFM consensus paper as the source for that change, and the perspective of “***6 is the new 4***” (American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine. “Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery.” Obstetrics and Gynecology 2014; 123:6093-711.)
Made even clearer our statement that prolonged early labor is not a complication. (But, of course, mom does need support with it, and we do give ideas for how to improve progress.)
Changed words used to describe fetal heart rate issues. New terms are ***normal, indeterminate, and abnormal***. Outdated terms include fetal distress, non-reassuring heart rate, and fetal intolerance of labor. http://www.ncbi.nlm.nih.gov/pubmed/19546798
Fetal scalp sampling removed (apparently there’s not an FDA approved kit for doing it) But do recommend fetal scalp stimulation (scratching baby’s head) as a tool for evaluating an indeterminate heart rate – if you scratch baby’s head and heart rate speeds up, good sign
Added more on delayed cord clamping. (to learn more about it, see Penny’s video here: https://www.youtube.com/watch?v=W3RywNup2CM) Note: cord blood CAN be collected for storage or donation after delayed clamping – it is collected from the placenta.
Added more on hormones of labor and on hormonal interaction during fourth stage. Included reference to ‘Pathway to a Healthy Birth’ by Sarah Buckley, available at childbirthconnection.org.
We are adding Penny’s Road Map of Labor (newly revised) to the back of the book, so have brought references to it into this chapter and chapter 13.
Chapter 13 – When Childbirth Becomes Complicated
Changed the order of the sections. In the past, they were roughly in order from most common to least common. But that didn’t lead to a logical flow of topics. New order:
complications of pregnancy that affect labor: multiples, gestational hypertension
issues with transition from pregnancy to labor: premature birth, rapid birth, induction
challenges that arise in labor: prolonged labor, concerns about well-being
prolonged second stage
issues after the birth: third stage complications; premature or seriously ill newborns; infant death
Note: breech birth moved to chapter 7. Preterm labor divided up as follows: chapter 7 – warning signs and what to do if you think you may be in preterm labor; chapter 13 – when labor can’t be stopped and birth is inevitable
Shortened section on misoprostol, as current protocols do not appear to cause the severe health complications that happened when it was first used as an induction agent
Changed discussion of prolonged labor to match current ACOG recommendations. Prolonged labor should not be diagnosed before 6 centimeters dilation. After 6 cm, it still shouldn’t be diagnosed until she’s had not progress for 4 to 6 hours, even with AROM and Pitocin.
Note: ***this is a very significant change for childbirth educators to be aware of***. If more care providers start following these guidelines, labor will become longer on average, and students need to have expectations set appropriately! We need to talk more about not getting excited too early in prelabor, conserving energy in early labor, ways to aid progress in active labor but also not stress over a long labor. (e.g. it may take 5 – 7 hours to progress from 4 to 6 cm even if you’ve got contractions in the 5-1-1 pattern)
Childbirth educators used to talk about prolonged labor / back pain being mostly due to OP babies. Ultrasound studies have shown that isn’t always true (see Simkin 2010 – Fetal OP Position: state of the science), and that babies change position more in labor than we had thought. We can say that if you have any of these issues: slow labor progress, irregular or coupling contractions, back pain, or very severe pain, then there is something dysfunctional (“not quite right”) about your labor that needs to be corrected. It may be baby’s position, it may be something else. But whatever the cause, the things we’ve always recommended for slow labor and for back pain can help (e.g. positions and movement, counter-pressure and hip squeeze, addressing mom’s fears, hydration, etc.)
Prolonged second stage. Again, the ACOG recommendations have changed! There is no absolute maximum amount of time for pushing. ***Arrest of descent should not be diagnosed unless the mother has pushed at least 3 hours (2 hours if multip). Longer may be appropriate: for example, allowing one hour more if the mother has an epidural or if baby is malpositioned.***
Before instrumental deliveries are done, manual rotation of baby’s head should be considered. Before a cesarean is done, vacuum or forceps should be considered.
Previous edition said postpartum hemorrhage occurs in 20%. This was a typo. 😦 Should have said 2-5%. Updated this to say “about 5%” based on WHO and ACOG.
Chapter 14 – All About Cesarean
Updated “cesarean trends” section to address that rates have increased for all women across the board, and to address practice variations between birth places and how that influences cesarean rates at individual hospitals. Talk about the ACOG statement on need to reduce c-s.
Updated info on elective cesarean to reflect 2013 ACOG saying that if there are not medical reasons for cesarean, then vaginal delivery should be recommended. If elective is done, should be after 39 weeks.
Updated info on what counts as prolonged labor in need of cesarean (see chapter 13 notes)
Chapter 15 – What Life is Like for a New Mother Parent
Changed the order of topics for more logical flow
Replaced section on breast self-exams with new recommendations for long-term reproductive health care: Pap smear every 3 – 5 years. Under 40, clinical breast exam every 3 years. Over 40, may recommend annual breast exams and annual mammograms, or they may follow the USPFTF research-based recommendations for biennial mammograms starting at age 50
Chapter 16 – When Postpartum Becomes Complicated
Added brief info on PTSD after birth; noted that 5% of new dads experience PPMD; briefly address placental encapsulation (while noting research on its efficacy and safety is limited)
Chapter 17 – Caring for Your Baby
Tightened up some medical details to make room for some practical stuff like “how to hold a baby”, “dressing your baby”, “when and how to change a diaper” and typical wake-sleep patterns at 2 weeks, 4-6 months, and 2 years
Newborn procedures – removed silver nitrate and tetracycline from eye ointment options, leaving just erythromycin which is what is in current use. Changed hearing screening to note that it is now recommended for all babies. Added the pulse oximetry test. (learn more about this test: http://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html)
***Updated circumcision.*** New AAP guidelines say medical benefits outweigh risks, but not enough to recommend routine circ. http://pediatrics.aappublications.org/content/130/3/585.full; New CDC guidelines say circumcision reduces risk of HIV and 2 other STI’s, and given concerns over the spread of HIV we should do all we can to prevent, and it’s safer to circumcise a baby boy than an older boy or man http://www.cdc.gov/nchhstp/newsroom/docs/MC-factsheet-508.pdf. However, AAP says parents need to weigh benefits and risks, and CDC says delaying circ allows child to participate in decision-making. Note: there is a chair that can be used during the procedure rather than strapping baby to a board on his back – this leads to less distress for baby
Increased information about newborn cues, particularly disengagement cues, and overstimulation as a culprit in colicky behavior. Cited research that probiotics may help colic.
Updated vaccinations. Old edition didn’t really talk about the benefits, just all the reasons people might choose not to. Update covers benefits to child and community. Says the CDC believes that for the population as a whole, the benefits outweigh the risks, but some parents may have concerns about the risks. States that research does not show a connection between vaccines and autism. Suggests that if they want to opt out of vaccines or adjust timing they should do so only after research into benefits and risks and consultation with caregiver.
Chapter 18 – Feeding Your Baby
Split into two chapters. Feeding your baby and When Breastfeeding is Challenging. We did this because of feedback from students that it was overwhelming to see all the complications mixed in with the normal. Throughout the book, we separate typical from Complicated (chapter 7, 13, and 16) so that the complications info is there, but that it’s hopefully less anxiety inducing when it’s clearly labeled as the unusual circumstance.
In the past, lots of the information on general feeding practices no matter what they’re fed (when to feed, how much to feed, how to burp, spit-up, etc.) was in the midst of the breastfeeding content, so parents who were bottle-feeding might have skipped much of that important content, and only seen the info on bottles and formula at the end of the chapter. We re-organized the chapter a bit, to be: general feeding info, breastfeeding specific info, bottle-feeding (breast milk or formula) info, then a brief section on formula.
“Normal” breastfeeding challenges covered in Feeding Chapter: when your baby doesn’t get enough milk – ways to increase supply; breast fullness and tenderness, sore nipples and leaking
Issues covered in the “when breastfeeding is challenging” chapter: persistent sore nipples – causes and treatments; engorgement; plugged ducts; mastitis; persistent low milk supply; and situations that make breastfeeding challenging (cesarean, preemie / ill baby, multiples, nursing while pregnant / tandem nursing; working and nursing.)
Chapter 19 – When You’re Pregnant Again
Minor updates, including updated recommendations for books to read to older child.
Appendices
We will be moving the chart about pain medications to the website
We will add “The Road Map of Labor” graphic to the book, and have updated the “Summary of Normal Labor” chart to incorporate ideas from the road map
The new book will be available in March. We encourage you to check it out! We are also revising the Simple Guide to Having a Baby, which will be out in May 2016. It is similar content to PCN, but whereas PCN is written at a high school / college reading level, Simple Guide is 6th-8th grade reading level. It’s a good match for students with less formal education, for those for whom English is a second language, or those who are too busy to read the much longer PCN.
The collection of bacteria, viruses, fungi, and other organisms that live in and on the body. We have about 10 trillion human cells in our bodies, and about 100 trillion microbes. We have evolved in tandem with this microbiome for thousands of years. The balance of microbiomes varies throughout our body, and the bacteria found in our mouths is different than on our skin, which is different than in our intestines.
Why does the microbiome matter?
A balance of microbes leads to optimal health. An imbalance can lead to disease. For example, a vaginal yeast infection may occur when the healthy bacteria are reduced by antibiotics, allowing yeast to overgrow.
Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, and protect against infection.
An overgrowth of harmful bacteria can lead to infectious disease.
Disruption of the gut microbiota has been linked to inflammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers.
Many studies have shown that the presence of absence of specific microbes can cause life-long changes in immunity.
How does a baby’s microbiome develop?
During pregnancy
In the past, the womb was believed to be a sterile environment. However, microbes are found in the placenta, amniotic fluid, and in meconium. (The waste that accumulates in the fetal bowels.)
Maternal fecal microbes have been found in the uterine environment, leading to hypotheses that microbes from throughout the body are transferred through the bloodstream. And from there into the placenta, then the umbilical cord and the amniotic fluid.
Placental microbes are similar to the microbes in the mother’s mouth – especially types of bacteria that aid in the metabolism of food.
Healthy bacteria may benefit baby. For example, if the mother lived or worked on a farm, that might protect against allergies and asthma.
Others worry that unhealthy bacteria may affect baby. For example, obese women tend to have abnormal gut microbiota. This may be transferred to the baby.
Maternal diet affects the baby. E. coli bacteria (an unhealthy bacteria) was less common amongst babies whose mothers ate primarily organic foods.
At birth
During a vaginal birth, a baby is exposed to the microbes in mother’s vagina. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk.
When a baby is placed skin-to-skin on a parent, they are exposed to the parent’s skin microbiome. The baby’s skin, mouth, and digestive tract are “seeded” by whatever and whomever they first have contact with.
Through feeding
Breastmilk exposes the baby to more microbes. Several are gut microbes that influence digestion.
Breastmilk contains sugars (oligosaccharides) which are not digestible by babies, and whose role appears to be to nourish / feed a healthy microbiome in baby’s gut. These are also referred to as prebiotics. By helping healthy bacteria to grow, there is less room for unhealthy bacteria.
When solid food is introduced, the microbiome begins to evolve to a more adult-like combination of microbes.
Through the environment
As baby is held by various people, their microbiomes influence it.
As the baby starts to explore his world, crawling on the floor, playing outdoors, petting animals, and putting everything in his mouth, his microbiome shifts and evolves, becoming quite diverse by age 3. The “hygiene hypothesis” states that babies who are exposed to more symbiotic organisms have lower risks of asthma and allergies, and stronger immune systems.
What can interfere with the establishment of a healthy microbiome?
During pregnancy and labor
Antibiotics given to mom can affect the mix of microbes in the placenta, amniotic fluid and vagina. This disrupted microbiome is inherited by the baby.
At birth
Babies born by cesarean, and thus not exposed to vaginal bacteria, are at increased risk of asthma, allergies, obesity, diabetes, and celiac disease. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown differences in their gut bacteria as much as seven years after delivery. (Salminen)
After cesarean birth, instead of skin-to-skin contact with the parents, the baby’s first exposures are to hospital bacteria and the bacteria of hospital staff. (Babies in NICU were found to be colonized by bacteria from the health care staff, from medical equipment, and from the counter-tops in the NICU. – Brooks)
Newborn care
After any birth, if baby is wrapped in a blanket, and placed on a clothed parent, rather than skin-to-skin, the transfer of skin microbes is not complete.
Early baths remove / reduce protective vernix, vaginal microbiome, and baby’s own newly seeded skin microbiome. Those are replaced by hospital microbes.
If baby is given antibiotics, it reduces microbial diversity, and the number of both harmful and helpful bacteria. The impact lasts over 8 weeks. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of antibiotics, or prolonged use, can have long-term side effects, increasing risk of obesity or inflammatory bowel disease in later life.
Feeding
Formula-fed babies (even those who just had short-term formula feeding in the first few days) had increased harmful bacteria and decreased helpful bacteria.
What can parents and health care providers do to foster a healthy microbiome?
During pregnancy:
A mother can increase exposure to diverse healthy bacteria. Taking probiotic supplements may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. (Research cited in Collado) You can eat probiotic foods which introduce healthy bacteria, such as fermented foods and foods with live cultures. And you can eat prebiotics – foods with oligosaccharides which feed healthy bacteria – see the list at the end of this article. (Reed)
Minimize exposure to unhealthy bacteria, such as food-borne illnesses.
During pregnancy and labor: Minimize exposure to antibiotics. If they are needed, consider consuming probiotics or prebiotics after the course of antibiotics is complete.
If baby will be delivered by cesarean, a baby’s initial seeding is from hospital bacteria and skin microbes rather than vaginal microbes. You can expose the baby to vaginal bacteria by swabbing. Although swabbing does not colonize the baby as well as vaginal birth, it helps. (Swabbed babies had twice as much maternal bacteria as babies who were born by cesarean but not swabbed. Babies who were born vaginally had six times as much maternal bacteria.) Here’s the process:
Sample mom’s vagina: make sure the mother is HIV-negative, strep-B negative, and has an acid, lactobacillus-dominated vagina.
Place sterile gauze in the mother’s vagina. Incubate gauze for one hour. Remove prior to surgery.
After birth, wipe baby’s mouth, face and hands with the gauze.
Note: If the caregiver will not do this procedure, the mother and partner can do it themselves.
After birth, baby should go straight onto the mother’s body, skin-to-skin. (Consider bringing a blanket from home to cover baby, rather than using a hospital blanket.)
In the first hours, encourage people other than the parents to look but not touch.
Wait 24 hours after birth to bathe the baby.
Feed baby only breastmilk for as long as possible.
If a breastfeeding mother develops mastitis or a yeast infection, ask a lactation consultant about treatment with lactobacillus probiotics.
Giving probiotics to a baby can treat antibiotic-induced diarrhea, prevent eczema, reduce colic symptoms, and possibly reduce obesity in later life. (Studies cited in Arrieta and Collado.)
Let your child explore their world, with plenty of time outdoors, digging in gardens, and exposure to animals, both pets and animals at petting zoos.
Offer your child diverse foods, including: fermented foods and foods with live cultures (Yogurt, buttermilk, sour cream, kefir, sauerkraut and other fermented vegetables, tempeh, miso, soy sauce, kimchi, dosas and sourdough breads, kombucha, etc.) and prebiotic foods that are high in oligosaccharides (onions, garlic, legumes, asparagus, starchy vegetables like sweet potatoes, squash, turnips, parsnips, beets, and plantains)
Note: While many of those recommendations are supported by scientific research, not all have been adequately researched.
Here is a 2 page handout of this information to share with clients.
Azad MB, et al. 2013. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. CMAJ. Mar 19;185(5):385‐94. http://www.cmaj.ca/content/185/5/385.long
Canadian Medical Association Journal. (2013, February 11). Infant gut microbiota influenced by cesarean section and breastfeeding practices; may impact long‐term health. ScienceDaily. sciencedaily.com/releases/2013/02/130211134842.htm
Salminen, et al. (2004) Influence of mode of delivery on gut microbiota composition in seven year old children. Gut. 53: 1388 – 1389. http://gut.bmj.com/content/53/9/1388.2.long
(affiliate link.)
Transition to Parenthood 