Birth

At all times, a midwife is on call for you. The central line is: (604) 901-7806

The central number leads to a message that will tell you who is on call and how that midwife can be reached.

We will have a conversation about this during your prenatal visits based on the your specific needs. Here are some general guidelines for when to call us in labour:

Labour

Please page us day or night if you think you are in labour and have:

• Regular, strong contractions:

FIRST BABY: 3-2-1 Rule = consistent contractions every 3 minutes for over 2 hours that are over 1 minute long

SECOND or more BABY: 5-1-1 Rule = contractions every 5 minutes for 1 hour that are 1 minute long

• Not reached 37 weeks gestation
• Broken your water and you are GBS positive
• Broken your water and the water has a strong odor OR is any color other than clear OR baby isn’t moving normally
• Constant abdominal pain that does not go away
• Large amount of bleeding, more than mucousy “show”
• Persistent and severe mid-back pain
• A fever > 38^oC (if you feel hot or shivery, take your temperature)
• An outbreak of blisters anywhere around your genitals
• Blurry vision, double vision or spots before your eyes
• Concerns about fetal movement (less than 10 movements in 2 hours)

Heads-up calls

If we have expressed concern about where you live and how long it may take us to get to you, please give us a heads up as soon as you can, especially if you think things are building. Please talk to us about concerns you have if you live far.

DAY (between 9 am and 9 pm): If you suspect you may be in labor and/or your water has broken, page the midwife on call. A heads-up call can help us to arrange our day so that we will be available when you need us later.

NIGHT (between 9 pm and 9 am): If you do not need a midwife immediately, please wait until morning.  We appreciate our chances to sleep through the night, and having a perky midwife when labor gets hard may be just what you need. But if you know you are in active labor and need a midwife now, please page us!

When to call 911

• If your water has broken and you feel something hanging in your vagina (then get in a knees & chest position on the floor)
• If the birth is suddenly imminent and the midwife is not going to make it in the next few minutes

AFTER you call 911, call your midwife IMMEDIATELY.

Jules Atkins: (778) 808-2959
Lehe Spiegelman: (604) 603-0477

Planning for birth is like building your dream home … you envision the ideal structure beforehand, and then once everything is underway you revision and redraw your blueprints as circumstances arise. Sometimes the final outcome looks very little like the original plan, but is no less beautiful.

In answer to our client’s most common questions – as well as the numerous internet birth plans – we have written our own “birth plan” to help you know what to expect from us. Of course, the following is for a textbook spontaneous vaginal birth and your labor may demand a few variations, or a completely new plan!

Active labour

• Every attempt will be made for a midwife known to you to be designated your primary care provider for labor, and to remain so until the birth is over. Certain circumstances may make this impossible, such as illness, injury, extreme fatigue, etc.
• When a student midwife has been part of your care prenatally, she will usually be available for additional continuity and hands-on care during labor
• Any and all proposed procedures will be explained and discussed, except in emergency situations, when permission will be assumed and every effort will be made to debrief and explain afterwards
• Internal exams will be minimized
• Intermittent monitoring of the fetal heartrate with handheld Doppler will be used every 15-30 minutes once you are established in active labor, unless medically indicated to use continuous fetal monitoring. During pushing, monitoring will increase to about every 5 minutes.
• If continuous monitoring is indicated, a cordless & waterproof monitor will be used (when available and appropriate) so you can still walk around and/or use water
• Movement and position changes will be encouraged throughout labor
• You will be reminded to drink as much as possible
• You will be encouraged to eat to tolerance to keep up your energy, unless medically inappropriate (such as with an epidural, during an induction, etc. – in these situations clear fluids may still be encouraged)
• You will be reminded to urinate frequently
• A calm atmosphere is our goal: low lights, soft voices, etc.
• Lots of verbal encouragement when needed
• As many support people as deemed appropriate by the laboring mother will be welcome – on the understanding that if the situation gets hectic and there are too many people to maintain a safe and supportive atmosphere, or if anyone is found to be hindering effective labour, some or all may be asked to leave
• Your other children are welcome at the birth, as long as they each have their own support person and the option to leave if they are bored, tired or frightened. They are also welcome to participate in whatever way you and they feel comfortable.
• You will not be shaved – except minimally for cesarean section only; (what you choose to do for yourself is fine!)
• Unless you have extreme constipation, you will not be offered an enema
• We will not offer you drugs. We trust that you know your options and will ask for what you need.
• There are a number of situations where induction of labor may be offered or advised. If any of these arise for you, we will discuss risks and benefits of all options to help you make an informed decision as to how to proceed.
• If your labour needs to be induced, or your contractions need stimulation to continue to be strong, more natural methods such as walking, nipple stimulation, positions, homeopathics, breaking your waters, etc, will be offered before pharmaceutical methods, unless deemed clinically inappropriate or not preferred by you.
• We will wait for your bag of waters to break on its own, unless a clinical reason indicates that artificial rupture (breaking the bag of waters) may be helpful or necessary
• IV fluids will only be used for medical indications, such as epidural use, administration of oxytocin, serious dehydration causing a slowing of labor, etc.
• If it becomes necessary to transfer the care of you or baby to a doctor, we will stay with you in a supportive role throughout active labor, birth and postpartum
• A second midwife will be called to attend once the birth is judged to be imminent
• Until the birth is more imminent, or there is a clinical indication to transfer into the hospital, we will labor with you at home as long as safety and comfort allows (factoring in weather, traffic, distance to hospital, speed of your labor, etc.)
• If we have done a complete maternal and fetal assessment at home, we will phone ahead to let the hospital know we are coming. This way you can avoid the hospital intake process in the Assessment Room other than signing paperwork. As long as there is a room and a nurse available on our arrival, you will be admitted immediately.
• You will have a private room to labor in. It will have either a shower or a tub.
• A nurse will be present from second stage on, or if any interventions become necessary during active labor. During breaks and shift changes, this nurse will be replaced by another.
• You will have your choice of wearing your own clothes, a hospital gown, or nothing.
• During a normal delivery, you will be asked for permission before non-essential personnel are invited to be present (student nurses, interns, residents, etc.)
• We can communicate a desire for minimal medical student involvement but during medical consults or transfers of care made necessary by medical concerns or emergent situations, doctors may need the assistance of a resident, or a resident may be the first/only person available.

Homebirth:

Hospital birth:

Optional:

• Continuous verbal encouragement and/or use of distraction techniques
• Silent birth
• Sterile water injections for back labor
• TENS machine for pain relief (to be arranged prenatally by parents)
• Homeopathics – for pain relief, to encourage progress, to help optimize fetal position in pelvis
  • Instinctive and spontaneous pushing, unless mother asks for direction or it is deemed clinically necessary to help speed the birth, then calm encouragement
  • Frequent position changes
  • Use of gravity-positive positions, squatting bar/birth stool where available
  • Everything possible to help prevent tearing: positions, warm compresses, verbal coaching through crowning, etc.
  • No episiotomy except and unless deemed absolutely crucial that the baby needs to be born quickly (about 1/1000 chance!)
• Using a mirror to see when pushing
• Touching baby’s head as it starts to emerge (mom, partner, etc)
  • Unless requested, we will not announce the sex of your baby
  • Unless there is an overriding clinical or practical reason not to, baby will be delivered onto mom’s chest
  • Third Stage Management [see handout] … choose one:
• Active Management (default)
• Physiological management
• Physiological Management unless risk factors develop, (then Active Management)
  • Baby’s mouth and nose will not be suctioned “on the perineum “(i.e. when only the head is out)
  • Suctioning of baby after birth will be avoided except where medically necessary
  • The cord will not be clamped and cut until it has stopped pulsing (at least a number of minutes), unless there is a clinical or practical reason to do so
  • As much skin-to-skin contact as possible with mom will be encouraged. Failing that, then skin-to-skin with partner
  • Breastfeeding will be initiated as soon as possible
  • Midwife and one support person chosen by mom to be present after regional anesthetic effectively placed – in the event of general anesthesia, hospital policy is to not allow support people including partners in the OR
  • Baby and mom to be reunited as soon as possible – depending on the hospital this may average 10 minutes or 2 hours
• Waterbirth (only possible at home or BC Women’s)
• Mom or partner to catch the baby
• Donation of cord blood – needs to be arranged by parents before 32 weeks
• Lotus birth (not cutting the cord at all)
• Mother’s choice of who to cut the cord (except in OR, or emergent situation)
• Placenta to be shown to the parents
• Placenta to be kept by parents
• If it’s necessary for baby to be taken to the nursery, partner to go with baby
• Eye ointment – if chosen, not usually given until parents have had appropriate bonding time
• Vitamin K – if chosen, usually given during breastfeeding to minimize pain to baby
  • Delay of the Newborn Exam until parents have had bonding time, if possible
  • Test results recorded on Newborn Summary, accessible to parents through midwives (includes time of birth, Apgar scores, weight, length, head circumference, etc.)
  • If hospital birth, discharge as soon as mother and baby clinically stable and ready to go home… on average 4-6 hours after a normal, vaginal delivery with no drugs
  • MW home/hospital visit shortly before/after 24 hours
  • Exclusive breastfeeding will be supported: donor milk where available; formula to be used only for medical reasons; cup/syringe feeding instead of artificial nipples
  • Rooming in with baby, unless needing to be in the nursery for medical reasons
  • Feeding on demand (including guidelines to recognize when baby is demanding to be fed)
  • Circumcision is not done in the hospital, and must be arranged and paid for privately by the parents if they want it done
  • 24/7 pager availability for serious concerns
  • 3-4 home visits in the first week
  • 2-3 clinic visits in first six weeks
  • Flexible visit schedule, geared to mom & baby’s needs
• Longer hospital stay for special circumstances/convenience

Pushing:

Optional:

Birth:

In the event of birthing in the OR (forceps or cesarean):

Optional:

Postpartum:

Optional:

Now that you know what is “standard” or “routine” for midwifery care, you can create a birth plan that is more personal and specific to your needs and desires. As a communication tool, it only needs to include your unique wishes or priorities, not what is standard to care.

 

Sample Birth Plan

Name		Jane Preggers			Support people
Due date		1 Jan 2010			Family/friends	Eli (partner)
Planned place of birth			Home	Hospital	Doula	Eve
Hospital(s) registered at			Sechelt Hospital		Big brother/sister + support people	Hannah (age 5)
						Sarah (grandmother)
Suncoast Midwives
Midwives	Jules Atkins: (778) 808-2959
	Lehe Spiegelman: (604) 603-0477
	Student Midwife

Introduction

This is our first pregnancy, as Hannah is adopted. We have been trying for years to get pregnant and are very excited to share this experience with each other and our caregivers.

Priorities

Since I find baths very relaxing, I plan to use water for comfort, and I would love to have a waterbirth if possible

• My partner would like to help catch the baby
• I would like my midwife, or whoever is the first to see the sex of the baby to call it out
• When the cord is cut, I want to say a short Jewish prayer of welcome
• I have elected Vitamin K for my baby
• NO eye ointment, thanks

Preferences for Unexpected Events

We recognize that everyone’s first priority is a healthy mom and baby.

• I would like my partner to stay with me at all times if possible. If baby needs to be transferred to the nursery, we would like to go visit her/him as soon as I am able.

You may not believe us, but you don’t really need too many supplies to have a home birth. There are many birth supply options out there, including homebirth kits that you can buy from different online vendors.. We will supply you with a basic kit that includes the following:

• 20 underpads
• 2 water-resistant mattress covers
• 2 mesh postpartum underwear
• peri-bottle

You can gather many items from around your house, from friends or the local thrift shop. Have everything ready by 37 weeks.

Start off by designating a box or a basket that you will use to store all of your various homebirth supplies – a laundry basket works well. Avoid having supplies in different places around the house – we often show up to a labouring mama’s house without much time to scramble looking for important items!

Homebirth Kit Supplies List: The Essentials

• 20 underpads
  • ‘What are these?’, you might wonder – they are usually sold as incontinence pads. They range in size but most are 17″24. We suggest a minimum of 10 large and 10 small. We use them to catch any fluids such as amniotic fluid leaking or any bleeding.
• 1 Peri-bottle
  • Again, not a common household term/item. This is a squeeze bottle that is essential for the first few days after birth. The squeeze bottle can be filled with warm water or warm water plus healing herbs to help with diluting urine on stinging tears as well as improve healing to your perineum.
• 12+ Heavy Overnight Menstrual Pads
  • No ‘ultra-thins’, folks. Heavy duty only please.
  • Set aside six pads to make Frozen Pads for a soothing cool after the birth.
• 2 Garbage Bags
  • One for laundry, one for garbage. This is one of those essentials to help us help you keep your home tidy
• 2 Newborn hats
  • Make sure these are extra small! We use them in the first few hours to keep your newborn warm, but everyone knows that skin-to-skin with mama is the best way to keep your baby warm.
• 6-10 Newborn Receiving Blankets
  • These are often flannel or cotton big square blankets that you see used for swaddling babies.
  • We use these to dry off your baby after the birth. We know your baby is clean, but we want to make sure your baby is dry so that he/she can stay warm. Also, like the newborn hats, make sure that you give us items that you don’t mind if they get stained – nothing made with love by grandma that you want to keep forever.
• 1 Plastic Sheet
  • You can use this to wrap your mattress. Even though you may decide to birth you baby on the kitchen floor, a wrapped mattress might be a nice resting place in labour. A painter’s dropsheet works best (small size at your local hardware store). Shower curtains – not so good as they slide off the bed at crucial moments!
• 1 Large Ziplock Bag
  • We put your placenta in this bag.

Also, you should have your wallet with your care card somewhere safe and accessible at all times.

The Extras

This list can go on and on, but below are some of the extras that can make for a tidier, more organized birth.

• Towels
  • If you are planning to labour or birth in a tub, have at least a dozen of large towels on hand. Thrift stores are a great place to stock up on towels.
• Face towels
  • We often fill a mixing bowl with warm water so that we can apply warm cloths to your perineum as your baby is crowning as this may help prevent tearing.
• Extra bed sheets
  • Never hurts to have an extra set on hand.
  • A common midwife trick on making your bed for the birth: put a sheet on your bed. Wrap your mattress with your plastic sheet over top. Then add another sheet on top of your plastic sheet. After the birth when we help to strip your bed, we can put the soiled sheet in the laundry bag, discard the plastic sheet into the garbage bag, and voila! a fresh sheet already on the bed.
• Epsom salts and Perineal Healing Herbs
  • These are for after the birth and to help with perineal healing.
• Aromatherapy
  • You may have a favorite scent or essential oil that you want to have on hand.
• Bendy Straws
  • Keeping hydrated is essential. Have some straws on hand for when holding a glass to your lips may be tricky!
• Diapers 
  • Have some newborn diapers at home so you have one less reason to leave the house in the first few days.
• Tylenol & Ibuprofen
  • These are great for pain relief after the birth and can ease discomfort from after birth contractions, perineal tearing or any other aches and pains.

Nourishment

We can’t say enough how important food and hydration is in labour. Your body is working hard – keeping nourished and hydrated is essential. It is great to have different beverage options as well as easy and healthy snacks for when you are in labour. But make sure you have something grand in the fridge for after the birth when you are ravenous… Don’t forget to have some nutritious snacks for your labouring partner as well. Here are some ideas for you:

• Beverages
  • electrolyte drinks
  • Labour-aid
  • teas with honey
  • less-acidic juices, such as coconut water
  • broth
• Snacks
  • Fruit (frozen grapes very popular…)
  • crackers & cheese
  • yogurt
  • broth
  • energy balls/bars
• Victory Meal
  • Think about a meal you can have all ready to pop in the oven and dine on while your baby is nuzzled and nursing and you are ravenous from a hard day of work done. Lasagna or some fancy casserole are good options.

Water birth around the world

Water is revered in every culture for its life-sustaining and healing properties. Women have been using water in labour and birth for millenia .  Ancient Egyptian petroglyphs depict water births of babies destined to become preists or priestesses.  The oral histories of indigenous peoples on every continent – from New Zealand to Mongolia, Panama to Japan – include stories about women giving birth in the ocean tide pools, in streams and in shallow lakes.

In the 1960s, Igor Tjarkovsky, a swimming instructor and midwife, popularized water birth in Russia.  In 1983, Herman Ponette, an obstetrician, began installing birthing tubs in his hospital in Belgium.  Since then, he has attended over 5,500 water births.

In the United Kingdom, even the government recognizes the potential benefits of water birth.  In 1992, the UK House of Commons recommended that whenever possible, women have the option to birth in water.  Nearly half of all maternity hospitals in the UK  have installed birthing pools and there are at least 2,000 water births per year.

What are the benefits of water birth?

Many women find that being immersed in water during labour and birth gives them an increased sense of control, comfort and relaxation.  If you are the kind of person who enjoys spending time in water, you may enjoy the following benefits from birthing your baby in water:

• You may feel more relaxed and better able to cope with your contractions
• You may need less pain medication because your contractions are easier to cope with
• You may find it easier to move intuitively to ease your baby through your pelvis
• Your cervix may open faster and your labour may be shorter
• You may have less need for medication to help your labour because your contractions work better
• You may have less need for help from forceps, vacuum or caesarean to give birth to your baby
• You may have less need for an episiotomy and less chance of having a serious tear

Some people have also suggested that water birth is a gentler experience for baby as well as for mom.

Is water birth safe?

The research about the safety of water birth is not conclusive.  However, the existing studies seem to suggest that birthing in water is a safe option for women with healthy pregnancies and uncomplicated labours.

To understand the available evidence about water birth, you need to know a little about medical research.  The gold standard for a research study is a Randomized Controlled Trial (RCT), meaning that the subjects are randomly assigned to either a treatment group or a control group.  However, there have not been any good RCTs about water birth because most women would not be willing to be randomly directed to birth in water or on land.

The next best thing to an RCT is a cohort study.  A cohort study compares a treatment group with a control group but the subjects are not randomly assigned so there is a chance for bias.  There are a number of large cohort studies looking at water birth.  They have all found that when compared with land birth, water birth is associated with:

• Similar or lower rates of infection in mothers and babies
• Similar or better results on tests that evaluate the baby’s wellbeing after birth
• Similar or lower rates of babies admitted to special care nurseries
• Similar or lower rates of baby deaths

A case study describes the experience of one patient or a few patients.  Case studies are the weakest form of evidence, although they are sometimes the only way to learn about very rare problems.  A number of case studies have reported on babies who have become sick or died after being born in water.  However, these problems have not been reported by any of the larger, better quality studies.

What stops babies from breathing underwater?

A number of factors inhibit babies from breathing underwater at the time of birth:

• Hormones: You might be surprised to learn that your baby has already begun practicing breathing before birth, inside the uterus. Researchers have observed breathing movements in the human fetus as much as 40% of the time.  However, in the days before labour begins, breathing activity decreases dramatically because of prostaglandins, hormones released by the placenta which also play a role in starting labour.
• Temperature: Newborn babies are sensitive to temperature.  They are stimulated to breathe by the cooler temperature of air compared to the warm environment inside the mother.  However, when born into water that is at a similar temperature to the mother’s body temperature, they are not stimulated to breathe.
• Dive Reflex: Humans have a powerful dive reflex which maximizes their ability to hold their breath underwater.  This reflex is associated with the larynx, the opening to the lower airway.  The opening to the larynx is covered with more taste buds than the entire surface of the tongue.  These taste buds can distinguish between bodily fluids (like mucus, urine, blood, or amniotic fluid) and other foreign fluids (like water).  When they encounter a foreign fluid, they elicit the dive reflex.  The opening to the airway closes and the fluid is swallowed, not inhaled.  In addition, nerves in the face sense when the face is immersed in water and send messages to the brain.  The brain responds by inhibiting breathing, decreasing heart rate, and redirecting blood to the brain and heart where it is needed most.  This reflex helps to prevent babies from gasping for air when they are born underwater.
• Hypoxia: Babies are born experiencing acute hypoxia, meaning they are temporarily lacking oxygen. This inhibits breathing.  However, babies born experiencing severe, prolonged lack of oxygen may gasp for air.  As a result, your midwife will monitor your baby’s well being during labour.  If there are any signs that your baby may be experiencing a prolonged lack of oxygen, your midwife will ask you to get out of the water.

Guidelines for water birth

Whether at home or the hospital, there are some situations where birthing in the water may not be clinically advisable and your provider may ask you to get out at the last minute. Certain providers have different levels of experience and comfort with delivering the baby and/or the placenta in the tub, therefore you should ask beforehand, if this is important to you. As well, if you are planning to birth in hospital, you should check both what the facilities are like, and what your hospital’s policy is regarding waterbirth.

To help keep you and your baby safe while having a water birth you need to:

• be having a healthy pregnancy
• be 37 weeks gestation or later
• be in a warm (not hot) bath (between 36-37.5°C)
• have no strong medications such as morphine
• leave the water if your care provider has any concerns with your or your baby’s wellbeing

Can I have a water birth in the hospital?

Sechelt Hospital supports women to labour in the bath but do not support waterbirth.

 

What supplies do I need for a water birth at home?

To provide optimal pain relief, the water level needs to be deep enough to cover your whole belly. Therefore, unless your home has a deep soaker tub, a labor tub will likely need to be rented or bought.

• Birth pool – cheaper to buy; rentals usually have a heater
• Garden/waterbed hose, new
• Sink faucet attachment for hose, with reverse/draining ability (Y adaptor) – from aquarium/pet store
• Pump – foot or electric for inflatable pool
• Plastic and towels to surround pool
• Fish aquarium net (large size)
• Yoga mat for floor close to the pool
• Lots of extra towels
• Bath pillow, if sides not soft
• Birthing Buddies birthingbuddies.com
• Mama Goddess mamagoddessbirthshop.com
• Canadian Tire

Water Birth Resources

Websites

www.waterbirth.org

www.waterbirthinfo.com

www.babycenter.ca/pregnancy/labourandbirth/waterbirth

www.waterbirthstore.org

www.geocities.com/hotsprings/2840/whywater

www.yourwaterbirth.com

Books

CHOOSING WATERBIRTH – by Lakshmi Bertram

GENTLE BIRTH CHOICES – by Barbara Harper

WATER BIRTH: AN ATTITUDE TO CARE– by Diane Garland (2001)
Explores the practical issues of setting up a water birthing facility both at home and in a hospital environment, explains issues of maternal and newborn physiology, and discusses practical aspects of care during and after use of a birthing pool.

THE WATER BIRTH BOOK – by Janet Balaskas (2004)
This comprehensive guide from the UK author of Active Birth includes the history of birthing in water, the benefits of water in labour, choosing a water birth, and preparing for a water birth.

WE ARE ALL WATER BABIES – by Jessica Johnson and Michel Odent (1995)
Photography and text exploring our links with water from birth to death.

 DVDs

Birth Day (66 min)
Shows the birth of a midwife’s third child in her hot tub at her home in Xalapa, Mexico

The Art of Birth (29 min)
Australian film shows four gentle births in water (two in birth centers and two at home)

Birth Into Being: The Russian Waterbirth Experience (28 min)
Shows two births in the Black Sea and two births at home in a clear birthing pool

Research

Gilbert RE. Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. BMJ.319(7208):483-7, 1999 Aug 21.

Keirse MJ. Challenging water birth — how wet can it get?. Birth. 32(4):318-22, 2005 Dec.

Cluett ER. Nikodem VC. McCandlish RE. Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane Database of Systematic Reviews. (2):CD000111, 2004.

Johnson P. Birth under water–to breathe or not to breathe. British Journal of Obstetrics & Gynaecology. 103(3):202-8, 1996 Mar.

Newborns & Vitamin K. 

What is Vitamin K?

Vitamin K is a fat soluble vitamin that is necessary for normal blood clotting.

Since Vitamin K is not easily passed through the placenta to the fetus, in newborns the main source is bacteria in their guts that synthesize Vitamin K. Of course, because babies are born sterile, it takes days to weeks to develop the necessary bacteria.

Why do we offer a Vitamin K supplement?

In some babies, low levels of Vitamin K can make their blood less likely to clot. If the blood doesn’t clot, it will lead to Vitamin K Deficiency Bleeding (VKDB) – formerly called Hemorrhagic Disease of the Newborn.

Sometimes this bleeding is visible to parents and care providers, for example if the baby is bleeding without stopping from the cord site or a scratch on her face. But sometimes, there can be internal bleeding, which can’t be immediately seen from the outside until serious and potentially life-threatening damage has occurred.

Without Vitamin K supplementation, the incidence of VKDB is thought to be between 1.5% and 0.01%. (The wide variation is due to different feeding patterns and risk factors.) VKDB usually occurs from birth up to 12 weeks of age, but the risk remains until the baby is about a year old. The most common form of VKDB occurs within the first week of life.

The Canadian Pediatric Society recommends that all newborns receive an injection of Vitamin K within the first 6 hours of life. It has been in use in North America since the 1950s, and has reduced the incidence of VKDB to 1 in 1 million.

How is Vitamin K given?

The standard is to give Vitamin K as an injection in the upper thigh, within about 1 hour of birth. The injection is made up of the active ingredient (phytonadione) and a preservative (benzyl alcohol).

Are there any risks or side effects to Vitamin K?

The only known side effects to the injection are the momentary pain, and the potential for infection or nerve damage at the injection site (as with any blood draw or injection). In the past, 2 studies linked Vitamin K injection to childhood leukemia, but these studies have been discounted by follow-up studies.

Some parents worry that the pain of the injection may interfere with breastfeeding and bonding. In order to minimize this, we use the smallest dose and the tiniest needle possible. Usually, we wait until you have a good opportunity to cuddle with your baby and have started breastfeeding. Ideally we try and administer the injection when the baby is at the breast, in your arms, since babies feel less pain when they are nursing. Most babies tend to cry a little and then settle soon after the injection.

Are there risk factors for VKDB?

The general incidence of VKDB among babies who do not receive Vitamin K is thought to be about 1 in 10,000. However for some babies, the risk is higher than that. This includes situations where there is:

• Some medications taken during pregnancy (including: anti-convulsants, anti-coagulants, tuberculostatics and cephalosporins)
• Antibiotic use during labor
• There is some question as to whether early cord clamping increases the risk of bleeding due to fewer platelets and other factors being passed to the baby at birth
• Instrumental birth (vacuum or forceps)
• Need for resuscitation after the birth
• Bruising or birth injury
• Liver or bowel disease in the newborn
• Late onset of feeding (colostrum has a higher concentration of Vitamin K than breast milk)
• Inadequate breast milk intake
• Exclusive breastfeeding (there is more Vitamin K in formula than breast milk, however, there are many more benefits to breastfeeding whenever possible!)
• Surgical procedures after birth (doctors/mohels will not perform circumcision on babies who have not had a Vitamin K injection)
• More common in summer months

Are there any alternatives?

Oral Vitamin K

It is possible to give Vitamin K orally. It must be administered at the first feed, then again at 2-4 weeks, and again at 6-8 weeks.

Oral Vitamin K is thought to reduce the incidence of VKDB to 4 in 1 million. The disadvantages of oral Vitamin K include that there are no long term studies on its efficacy, that it is not absorbed as well as injected Vitamin K, and there may be unreliable intake of oral Vitamin K to start with (e.g. variable absorption or regurgitation). Some also question the effect on the baby of the sugar content in certain preparations of oral Vitamin K, especially since it is given so soon after birth.

There are a number of different preparations of oral Vitamin K. If you choose to use an oral preparation, it is your responsibility to purchase it. Your midwife will administer the first dose shortly after the birth, but it will be your responsibility to administer the other doses according to the schedule. Sources: Finlandia Natural Pharmacy in Vancouver; Bastyr Naturopathic College in Seattle; Family Health Clinic in Langley; most naturopaths. The injectable form can also be given orally.

Treating for Risk Factors

While the aforementioned risk factors increase the risk of VKDB, one third of babies who develop VKDB have no risk factors or prior warning.

Would I know if my baby might have VKDB?

Symptoms include, but are not limited to:

• Bruises, especially unexplained bruises
• Bleeding from the mouth, nose, umbilicus, circumcision site, and anus
• Hematomas
• Blood in the urine, stool or vomit
• Poor feeding
• Prolonged bleeding from puncture sites
• Difficulty breathing
• Bleeding within the abdomen or chest
• Enlarged liver

VKDB can also cause intracranial hemorrhage. Of the babies who contract late onset VKDB (after 8 days of life), half will have severe brain damage or death as the result of intracranial bleeding.

Symptoms of intracranial hemorrhage include, but are not limited to:

• Unusual sleepiness
• Apathy
• Irritability
• Agitation/screaming
• Vomiting
• Tense fontanels
• Spasms
• Touch sensitivity
• Unusual posture

What is the newborn eye medication?

In Canada, it is standard practice to give prophylactic treatment to the newborn’s eyes with an antibiotic ointment. The antibiotic most commonly used is erythromycin. In the past silver nitrate drops were used but this is no longer the case.

Why is this treatment done?

The purpose of this prophylactic treatment is to prevent eye infections caused by the sexually transmitted diseases Chlamydia and Gonorrhea. If these organisms are present in the mother’s vagina during birth, they can be passed onto the baby and lead to infection. Eye infection due to Chlamydia is the leading cause of blindness in the developing world (where antibiotics are not readily available). In Canada, this result is extremely rare.

How and when is the medication given?

The ointment is similar in texture to petroleum jelly. It is squeezed from a tube directly into the baby’s eyes within an hour after birth.

What are the downsides of treatment?

• There is no method of treatment that is 100% effective in preventing infection. According to the American Centre for Disease Control, after antibiotic prophylaxis 15-25% of infants exposed to Chlamydia will still develop conjunctivitis (eye infection or irritation).
• In some cases the treatment itself causes an irritation of the eyelids, also known as chemical conjunctivitis, which may create a route of entry for various infections.
• Treatment will cause blurred vision for a few hours after being given. Because of this, some parents are concerned that the ointment may interfere with bonding by blurring vision or causing the baby to become fussy. To minimize any negative side effects, it is possible to delay application for the first hour of life, giving mom and baby time to bond and have their first feed. If the medication is given just before your baby falls asleep, the majority of it will be absorbed by the time your baby wakes up again.
• Another concern is exposure to antibiotics, which can cause system imbalance: antibiotic-resistant, infection-causing bacteria continue to grow, while other normal and healthful bacteria are killed. Because of the minimal amount of antibiotics in this treatment, this is not considered a large concern.

What if I know I don’t have an STD?

You were probably tested for Chlamydia and Gonorrhea earlier in your pregnancy. (Check with your caregiver.) If you are confident that you have not acquired either of these infections since then (assuming the results were negative or you received treatment), you may decide not to give any eye medication. This includes being absolutely confident that your sexual partner(s) do not have these diseases, which they may have passed on to you.  Since both of these diseases can be “silent”, do not rely on being symptom-free as a sign that you or your partner(s) do not have an infection.

However, tests for Gonorrhea and Chlamydia are only accurate 85% of the time.

If you know, or strongly suspect, that you have Gonorrhea, your baby will need more than just this treatment. Both you and baby need to be treated with IV antibiotics.

Are there any alternative treatments?

Some mothers will express breastmilk, and apply this to their baby’s eyes. We know that breastmilk is full of antiviral, antibacterial and healing properties, but it has never actually been proven effective in preventing eye infections due to Chlamydia or Gonorrhea.

What do I do if I suspect infection in my baby’s eyes?

Please note that some redness and swelling on your baby’s eyes is normal, especially in the first few days. Whether your baby had treatment or not, if you suspect infection, report this immediately to your caregiver. Cultures can be taken to determine which organism is responsible and appropriate treatment given.

What is the third stage of labour?

In medical terms, the ‘third stage of labour’ (or simply ‘third stage’) describes the time from the birth of the baby until the placenta is delivered.

However, third stage is much more than just a medical event. It represents the time just after your baby has been born, when your body stops being pregnant and you become a mother. Your baby begins to adjust to life in the outside world. Your pituitary gland releases the hormone oxytocin which causes your uterus to contract and expel the placenta. This process is best facilitated by an environment that is quiet and peaceful, and in response to being close to your baby (especially when there is skin-to-skin contact). Oxytocin release is further stimulated by breastfeeding.

Why do I need to think about the third stage while I am pregnant?

The third stage, and shortly after, is when the potential for bleeding is the highest. In the third world, postpartum hemorrhage (PPH) is still the leading cause of death for women of childbearing age. Of course, in Canada where we are better nourished and have access to emergency medications, this is rarely true. But PPH can still have serious consequences, including the need for further medical intervention.

Short term consequences of PPH

• Administration of emergency drugs
• IV fluids
• Manual removal of the placenta
• Blood transfusion
• Increased hospital stay
• In extreme cases, hysterectomy

Longer term consequences of PPH

The major cost of PPH is anemia. It is normal for new mothers to be tired, but to be anemic as well can make coping exceptionally difficult. The complications of being anemic postpartum include:

• Interference with bonding due to extreme exhaustion
• Decreased milk production as the body’s resources go into producing blood cells
• Constipation from taking iron supplements
• Increased susceptibility to infection
• For susceptible women, precipitating a slide into postpartum depression

Are there risk factors that increase the chance of PPH?

History	Previous PPHPrevious retained placenta
Pregnancy complications	High blood pressure
Medical factors	Clotting disorderUterine fibroids
Anything that especially stretches the uterus	Large baby (>4kgs or 9lbs)Polyhydramnios (extreme amount of amniotic fluid)Twins
Labour factors	Precipitous birth (<3hrs)Prolonged laborProlonged pushing stage Prolonged third stage (>30 minutes) Full bladder Uterine infection Induction/Augmentation Shoulder dystocia
Mode of delivery	Forceps/vacuumCesarean section

Are there any ways to minimize the chance of PPH?

There is no doubt that the use of uterotonic (causing uterine contraction) drugs has saved many lives which would have been lost to PPH throughout the world. Delivering the placenta as quickly as possible has also been shown to decrease the chance of PPH. This can usually be done by using careful traction on the umbilical cord to ease the placenta out. Once the placenta is out, promoting efficient contraction of the uterus will minimize bleeding. This can be promoted by massaging or rubbing the uterus from on top of your abdomen.

The combination of 1) uterotonic drugs, 2) controlled cord traction, and 3) uterine massage, is called Active Management of Third Stage. Active Management to prevent PPH has become the standard of care in many places.

Does this mean the cord will be cut right away?

Immediate clamping of the umbilical cord used to be part of Active Management but has not been shown to be effective in minimizing blood loss. Because of this, and because there are other useful reasons to not clamp the cord immediately, your baby’s cord will be left intact until it has stopped pulsing UNLESS the baby needs to be resuscitated and this cannot be done with the cord intact OR you are actively hemorrhaging and emergency measures are hampered by having the baby still attached.

Are there any alternatives to Active Management?

The alternative to Active Management is to let the third stage happen naturally, which is called Physiological Management. Mainly this means you will not be given a shot of prophylactic oxytocin. Your body will be supported in delivering your placenta as efficiently as possible. For example, nipple stimulation (such as with breastfeeding) which causes natural oxytocin production can be used if the placenta is slow in coming.

Considerations in third stage management

Active Management

• Less pain from the oxytocin injection when given at the moment of birth: You likely won’t even know you had it, unlike if given a few minutes later when you will very much feel this uncomfortable injection.
• Labour is completed more quickly
• Lower chance of needing emergency drugs to control bleeding, some of which can cause negative side effects such as nausea, vomiting, diarrhea or high blood pressure.
• If you do not accept blood products, active management will lower your chance of needing a blood transfusion
• If you are planning a home birth, active management will lower your chance of needing to transport to hospital due to blood loss
• If you are anemic prenatally, even minimal blood loss will affect you

Physiological Management

• Less likely to experience the most common side effect of oxytocin which is uterine cramping. This is less common with first-time moms.
• There are some risks with controlled cord traction such as snapping of the cord making it more difficult to deliver the placenta quickly, the risk of pulling out an incompletely separated placenta, and the very small risk of causing the uterus to invert which will require immediate action to reverse.
• There can be a risk if there is an undiagnosed twin (although this is rare due to the extensive use of ultrasound scans in pregnancy).
• If you develop risk factors in labor, it’s not too late to choose to have Active Management. In fact, your careprovider is likely to recommend this.
• If after some time your placenta fails to separate, or you are bleeding significantly, you should prepared for your careproviders to act quickly in recommending or giving emergency drugs.

LABOUR AID for mom

Research shows that being well hydrated increases efficiency of your uterus: in other words, promotes faster and easy labor!

Recipe:

Steep the following herbs in 250mL boiling water.

• 1/4 Cup Raspberry leaf
• 1/4 Cup Nettles
• 1/4 Cup Alflafa

Strain and add 1 Litre of water plus:

• 1/3 Cup Maple Syrup
• 1/2 Tsp Salt
• Half a lemon squeezed
• 2 crushed tablets of Calcium-Magnesium

Stir these ingredients together and set aside for the birth.

Raspberry and Nettle are great sources of calcium, iron, phosphorus, vitamins A, C, E &D. They are well known for promoting optimal uterine function and preventing hemorrhage. Mint is a great energizer as well as a good source of potassium. Nettle & Alfalfa both increase the available vitamin K and hemoglobin in the blood: good for mom and baby!

Maple syrup is full of minerals and gives natural energy as well as taste.  The salt, calcium and magnesium, which are essential in effective muscle contraction, create a good electrolyte balance.

Postpartum Recipes

Frozen pads

Peri bottle OR flip-top bottle6 Maxi pads (use the overnight size)Lavender essential oil OR Calendula tincture

While the thought of anything frozen on your girl parts may not be appealing now, if you use these for the first 2-3 days after the birth, you will decrease swelling and speed healing.

Strain and cool. Place 5 or 6 pads on a cookie sheet. Fill your peribottle with water. Add 4 drops of lavender oil (antibacterial) &/or a dropper of Calendula tincture (healing), if you like. Shake. Use the peribottle to spray the pads – they should be very wet but not drenched – it may take 4-5 refills of the bottle. Freeze the pads overnight on the cookie sheet, then transfer them to a plastic bag.

Perineal Healing Herbs

Shepherd’s purseUva ursiLavenderThymeComfrey	Epsom salts	Castor oil4x4 gauze	Various herbalists, including Gaia Gardens Herbal Pharmacy, sell a premixed Perineal Wash, which can be substituted for this combination of herbs, if you like.
Make a strong infusion from herbs. If not using warm, store in the fridge or freezer. Strain and fill your peri bottle Strain the liquid into a bath with Epsom salts. Soak and enjoy! After straining the herbs, add the castor oil to the wet mash of herbs. Make an herb burrito by wrapping the mash in the gauze. Use the burrito like a pad, once a day. It can even be chilled to help decrease swelling. Peri wash: Sitz bath: Peri burrito:

RICH MILK TEA aka Fussy Baby Tea

4 parts Fennel seed2 parts Nettle2 parts Raspberry leaf1 part Blessed Thistle	Use four to six tablespoons of herb mixture per quart of water. Add herbs to cold water and bring to a slow boil over low heat. Remove from heat and infuse for twenty minutes. Drink three to four cups daily.
Blessed Thistle is also known as Mother’s Milk Thistle.  It is widely used for enhancing milk flow as well as dealing with postpartum depression. Eliminate the Blessed Thistle if you are engorged or have issues with overabundance of milk. Fennel, which is the active ingredient in Gripe Water, will come through in your breastmilk to help baby’s digestion stay calm.