tag:theconversation.com,2011:/us/topics/vaginal-birth-51587/articlesVaginal birth – The Conversation2023-08-18T02:08:23Ztag:theconversation.com,2011:article/2054772023-08-18T02:08:23Z2023-08-18T02:08:23ZCurious Kids: why do babies cry when they come out of their mum?<figure><img src="https://images.theconversation.com/files/543119/original/file-20230816-21-5r1861.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C995%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-78559918">Shutterstock</a></span></figcaption></figure><blockquote>
<p>Why do babies always cry when they come out of their mum? – Nam, 12, Hanoi, Vietnam</p>
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<p><a href="https://theconversation.com/au/topics/curious-kids-36782"><img src="https://images.theconversation.com/files/291898/original/file-20190911-190031-enlxbk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=90&fit=crop&dpr=1" width="100%"></a></p>
<p>When babies are born, they all seem to cry. We see this a lot <a href="https://www.goldderby.com/gallery/best-tv-births-ranked-worst-to-best/tvs-most-memorable-births-little-house-ont-the-prarie/">on TV</a>.</p>
<p>But not all newborn babies cry straight away. Here’s what’s going on.</p>
<h2>What happens at birth?</h2>
<p>When a baby is born, they move from their mum’s warm body, and out of their dark, watery world into a much cooler, drier and brighter one.</p>
<p>It’s a bit of a squeeze. As the baby comes out from their mum, the cooler air hits their wet skin. </p>
<p>The cooler air makes them gasp. They also gasp when the midwife or doctor touches their body to help them come into the world.</p>
<p>That gasp is their first breath, which usually comes with a cry. And when this happens the gasp or cry triggers an amazing <a href="https://www.youtube.com/watch?v=zTXmaVgobNw">change</a> in how the baby gets oxygen and moves it around their body.</p>
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Read more:
<a href="https://theconversation.com/curious-kids-why-do-we-cry-119814">Curious Kids: why do we cry?</a>
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<h2>What changes?</h2>
<p>In the womb, babies depend on their mum for oxygen – via the <a href="https://theconversation.com/explainer-what-is-placenta-28851">placenta</a> and <a href="https://theconversation.com/ive-always-wondered-whats-behind-the-belly-button-84598">umbilical cord</a>.</p>
<p>The placenta looks a bit like a pancake and filters oxygen-rich blood from the mum. The umbilical cord then pumps that to the unborn baby.</p>
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<a href="https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Unborn baby with umbilical cord and placenta" src="https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543140/original/file-20230817-17-84peqv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The placenta, on the left, and the umbilical cord work together to send oxygen from the mum’s blood to the unborn baby.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-fetus-727111807">Shutterstock</a></span>
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<p>But once babies are born, their first breath or cry triggers a whole range of changes to the way their heart moves blood around their body. So, rather than breathing fluid from the womb, they can now breathe air and get oxygen into their lungs just like we do. </p>
<p>The process of being born also squeezes water out of the baby’s lungs, allowing them to work properly.</p>
<p>A newborn baby crying is a sound parents and health workers are very <a href="https://www.romper.com/p/why-do-babies-cry-at-birth-the-answer-will-probably-surprise-you-18746386">happy</a> to hear. That’s because it usually means the baby is well and won’t need any extra help to breathe.</p>
<p>But not all newborn babies cry. And it’s not always something to be worried about.</p>
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Read more:
<a href="https://theconversation.com/curious-kids-is-it-true-that-male-seahorses-give-birth-92843">Curious Kids: Is it true that male seahorses give birth?</a>
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<h2>Why don’t all babies cry?</h2>
<p>Sometimes this switch to moving oxygen around the body just like us <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/persistent-pulmonary-hypertension#:%7E:text=In%20persistent%20pulmonary%20hypertension%2C%20also,difficult%20birth%2C%20or%20birth%20asphyxia.">does not happen smoothly</a>.</p>
<p>There might be problems with the baby’s heart, or there may have been a difficult birth. For instance, the baby might have been very short of oxygen in the womb and need some help to start breathing when they are born. </p>
<p>Sometimes there’s a delay in babies crying. </p>
<p>Babies born by caesarean section – when doctors operate on the mum to lift the baby out of her womb – might be <a href="https://link.springer.com/article/10.1007/s00404-019-05208-7">slower</a> to breathe and cry. That’s because they don’t have the fluid squeezed from the lungs like they do when born through the vagina. </p>
<p>Sometimes newborn babies don’t cry at all.</p>
<p>Babies born in water (known as a <a href="https://www.bellybelly.com.au/birth/doulas/preparing-for-a-water-birth/">waterbirth</a>) may have lots of warm water around them and not even realise they are born. That’s because they don’t feel cold air as they come into the world; they are often in their mother’s arms in the water. So they tend to just <a href="https://www.sarawickham.com/questions-and-answers/whats-an-aqua-apgar/">breathe quietly</a>, and turn pink (showing they are getting enough oxygen), without crying.</p>
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<p><em>Hello, Curious Kids! Do you have a question you’d like an expert to answer? Ask an adult to send your question to curiouskids@theconversation.edu.au</em></p><img src="https://counter.theconversation.com/content/205477/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with The Australian College of Midwives</span></em></p>Crying triggers changes in how a newborn baby gets their oxygen. But not all new babies cry, and it’s not always a problem.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1780322022-03-08T03:13:30Z2022-03-08T03:13:30ZPrivate obstetric care increases the chance of caesarean birth, regardless of health needs and wishes<figure><img src="https://images.theconversation.com/files/450312/original/file-20220307-83366-7stmow.jpg?ixlib=rb-1.1.0&rect=48%2C8%2C5365%2C2930&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/baby-being-born-via-caesarean-600w-50320798.jpg">Shutterstock</a></span></figcaption></figure><p>Women in Australia are more likely to have an unplanned caesarean birth if they give birth in a private hospital rather than a public hospital – independent of their health status during pregnancy or their birth plans. Our recent <a href="https://www.sciencedirect.com/science/article/abs/pii/S0277953622000326">study</a> showed an unplanned caesarean birth was 4.2% more likely in a private hospital compared with a public hospital. For first-time mums, it was 7.7% more likely.</p>
<p>Many <a href="https://bmjopen.bmj.com/content/bmjopen/7/8/e016600.full.pdf">studies</a> have pointed to a link between private obstetric care and higher rates of caesarean births. But it’s been difficult to tease out the effects of women who may need or want a caesarean birth. We can’t look to the gold standard of evidence in the form of a randomised trial, because it would be unfeasible and unethical to randomly assign women to public and private care. </p>
<p>Instead, in this study we focused on a large data set of over 289,000 births in NSW between 2007 and 2012, and used a method developed to approximate a randomised trial. Two-thirds of women received public care, while 27% gave birth in a private hospital (7% had a private obstetrician in a public hospital). Women in our study had low risk pregnancies right up to the start of labour and did not plan to have a caesarean. This approach took out the effect of maternal choice and health needs, leaving only the impact of care received: private or public.</p>
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Read more:
<a href="https://theconversation.com/how-to-manage-pain-during-childbirth-what-the-research-says-148561">How to manage pain during childbirth: what the research says</a>
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<h2>Two different health systems</h2>
<p>Caesarean birth is a necessary and life-saving surgery when a clinical need exists. However, caesarean birth has also been <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/birt.12348">linked</a> with a range of short and long term adverse child health outcomes, such as respiratory infection, eczema and metabolic disorder. So unnecessary caesarean births may involve increased risk without clear benefit. </p>
<p>In <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/fourth_atlas_2021_-_chapter_1._early_planned_births.pdf">Australia</a>, 35% of all babies were born via caesarean birth in 2017. Of the surgeries performed before the pregnancy was full term, over 40% were without a medical reason. Some of this is due to maternal choice, but international studies have shown that <a href="https://academic.oup.com/eurpub/article/15/3/288/483999">convenience</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0167629699000090">payment</a> to the doctor or hospital also matter.</p>
<p>In Australia, the way hospitals and providers are paid could be an important factor in birth outcomes. Private doctors and hospitals are employed and paid differently from their public counterparts, so they face different incentives to intervene during labour and childbirth. </p>
<p>Private obstetricians are paid on a fee-for-service basis to attend the birth. By contrast, publicly appointed obstetric and midwifery staff are <a href="https://www1.health.nsw.gov.au/pds/ArchivePDSDocuments/IB2019_028.pdf">paid</a> on a salary basis for agreed hours. This means private obstetricians receive more income, the more births they can attend. In some <a href="https://academic.oup.com/qje/article-abstract/123/2/795/1930885">cases</a>, caesarean birth may also be seen as a method of risk management given the uncertainty of prolonged labour.</p>
<p>Hospitals also receive different payment based on whether a birth was caesarean or vaginal, reflecting the relative complexity of caesarean birth. Caesarean birth is a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/1D47CB6E5326A3C8CA257BF000217984/$File/The%20HCP%20Annual%20Report%202019-20.xlsx">high-cost procedure</a>: an average A$11,782 charge for caesarean birth, compared to A$8,388 for a vaginal birth in a private hospital. In our study, there were more than 3,200 “extra” caesarean births in private hospitals, that is, births that would have been vaginal births in the public system.</p>
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<h2>Private choices, caesarean outcomes</h2>
<p>In Australia, women who give birth in a public hospital have care provided by appointed midwives and obstetricians. If they have the resources, some women may decide to pay for care from a private obstetrician of their choice, either at a private or a public hospital (with reimbursement from their private health insurer). For women who wish to schedule a caesarean birth without health reasons – as a matter of convenience or because they are nervous about vaginal birth – private care is often the only option. </p>
<p>Our research is the first to measure the impact on the type of birth of having a private obstetrician in a public hospital, as well as the impact of giving birth in a private hospital. </p>
<p>We found a smaller effect of having a private obstetrician in a public hospital, which raised the probability of caesarean birth by 2.1%. This could be due to the influence of both the culture in a less-interventionist birth unit led by midwives, as well as the dominance of appointed staff, in public hospitals. </p>
<p>By contrast, we found a larger increase of 4.2% for women who gave birth in private hospitals. Aside from possible payment and convenience incentives, this could also be due to the more interventionist culture in private hospitals. Again, these increases in the likelihood of a caesarean birth were independent of health need at the onset of labour or prior birthing intention. While many caesarean births may occur due to complications during labour, there is no evidence to suggest these complications are more common in private hospitals. </p>
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<a href="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman holds very young baby close" src="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450313/original/file-20220307-85251-18eskka.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Caesarean births cost the system more than vaginal births.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/portrait-images-half-african-thai-600w-1922320169.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/vaginal-birth-after-caesarean-increases-the-risk-of-serious-perineal-tear-by-20-our-large-scale-review-shows-173249">Vaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows</a>
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<h2>Valuing autonomy</h2>
<p>Our results have meaningful implications for women choosing their antenatal and birth care, as well as the health system supporting them. Women <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002937802701890">value</a> their autonomy and participation in the decision-making process when it comes to labour and childbirth.</p>
<p>Women may choose a private obstetrician for reasons of continuity of care or because of a recommendation. They may prefer the amenities in a private hospital. Our study adds to a <a href="https://bmjopen.bmj.com/content/7/8/e016600.abstract">body of evidence</a> about the likelihood of surgical intervention in different settings. Women should seek information about their care choices and advocate for their preferences around intervention with their midwife or doctor.</p>
<p>Unnecessary caesarean births mean we are not using scarce health system resources in the best way. This research calls for a rethink of the Australian private health insurance system, which supports this diversion of funding and specialists towards unnecessary care that could carry increased risks for birthing mother and child.</p><img src="https://counter.theconversation.com/content/178032/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Serena Yu receives funding from the National Health and Medical Research Council which supported this research. She also currently receives funding from the Medical Research Future Fund.</span></em></p><p class="fine-print"><em><span>Caroline Homer receives funding from National Health and Medical Research Council which supported this research. She is a Life Member of the Australian College of Midwives and the immediate Past President.
</span></em></p><p class="fine-print"><em><span>Denzil G Fiebig receives funding from the National Health and Medical Research Council which supported this research. He also currently receives funding from the Medical Research Future Fund.</span></em></p><p class="fine-print"><em><span>Rosalie Viney receives funding from the National Health and Medical Research Council that supported this research.
</span></em></p><p class="fine-print"><em><span>Vanessa Scarf receives National Health and Medical Research Council which supported this research. She works as a midwife in a hospital on a casual basis. She also worked on the NHMRC funded Birthplace in Australia Study as the Project Coordinator.</span></em></p>We looked at almost 300,000 births and found those mothers in the private system were more likely to have a caesarean – even if they didn’t really want or need one.Serena Yu, Associate Professor, University of Technology SydneyCaroline Homer, Co-Program Director: Maternal and Child Health, Burnet InstituteDenzil G Fiebig, Professor, UNSW SydneyRosalie Viney, Professor of Health Economics, University of Technology SydneyVanessa Scarf, Lecturer in Midwifery, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1732492022-01-27T19:08:45Z2022-01-27T19:08:45ZVaginal birth after caesarean increases the risk of serious perineal tear by 20%, our large-scale review shows<figure><img src="https://images.theconversation.com/files/442175/original/file-20220124-23-enfx0j.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5458%2C3655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/mother-newborn-child-birth-maternity-600w-1936891393.jpg">Shutterstock</a></span></figcaption></figure><p>Pregnant women who previously birthed by caesarean section are presented with a choice: whether to try for a vaginal birth, or book in for a repeat caesar. </p>
<p>Those mulling over a vaginal birth are counselled at length about the risk of a rare but nasty outcome – the uterus rupturing while labour is in full flight. </p>
<p>But new research looking at 130,000 births over five years has uncovered an increased risk of another outcome women deserve information about: extensive tearing around the vaginal region during birth.</p>
<p>Our new study, <a href="https://pubmed.ncbi.nlm.nih.gov/34913246/">published</a> in the British Journal of Obstetrics and Gynaecology, hones in on the risk of vaginal trauma for those who birth vaginally after a prior caesarean. This kind of birth trauma relates to significant injury to a woman’s perineum, the important region between the vagina and anus. The perineum anchors many pelvic floor muscles that help control the bladder and bowels.</p>
<p>We defined serious birth injury as a tear in the perineum that <a href="https://www.thewomens.org.au/images/uploads/fact-sheets/Perineal-tears-third-and-fourth-degree.pdf">extends</a> into the anal sphincter – the delicate ring of muscle that helps us control our bowels. Damage to this muscle is called a third-degree perineal tear. </p>
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Read more:
<a href="https://theconversation.com/explainer-vaginal-birth-after-caesarean-48328">Explainer: vaginal birth after caesarean</a>
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<h2>What we studied</h2>
<p>The study looked at 130,000 births in Victoria and compared the risk of a third-degree perinatal tear among first-time mums with those who birth vaginally after a prior caesarean (sometimes referred to as a <a href="https://www.acog.org/womens-health/faqs/vaginal-birth-after-cesarean-delivery">VBAC</a>). In our study, vaginal birth included women birthed without any medical assistance, and births by forceps or the ventouse (vacuum birth). Anything but birth by caesarean.</p>
<p>The results were clear: a vaginal birth after a previous caesarean increases the chance of significant vaginal trauma (third-degree tear) by 21% (albeit from a low baseline rate).</p>
<p>A potential reason for this increased risk might include a mismatch between a uterus that has birthed before and a perineum that has not. If this is the case, the labour progresses quickly, which does not allow enough time for the perineum to stretch naturally. However, the real reason for this risk is unknown and further research is needed.</p>
<h2>Lifelong impacts</h2>
<p>Once a vaginal birth injury occurs, the tears are immediately repaired by obstetricians. Many women heal fully – but some who sustain a third-degree tear during birth develop distressing issues that never disappear, despite expert care, including from specialist physiotherapists. </p>
<p>Symptoms can include an ongoing dragging sensation in the pelvic floor, or true prolapse of the vaginal walls. Sometimes, coughing or sneezing can cause urine leakage. And for some, jogging becomes too hard due to leaking of urine and pelvic discomfort. Others might suffer from reduced faecal control and even the odd episode of faecal soiling. Sex can be painful.</p>
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<a href="https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman with caesar scar holds baby" src="https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442177/original/file-20220124-13-zzb927.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Women who had a caesarean birth the first time around are at greater risk of serious birth injury from a subsequent vaginal birth.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/closeup-woman-belly-scar-cesarean-600w-1883782888.jpg">Shutterstock</a></span>
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<h2>This doesn’t mean women shouldn’t consider VBAC</h2>
<p>This increased risk of injury does not make it unsafe for women who have had a caesarean before to try for a vaginal birth. But our results should be incorporated into counselling of these women about their choices.</p>
<p>Since the risk of vaginal birth injury including the anal sphincter sits at <a href="https://www.safetyandquality.gov.au/sites/default/files/2021-04/perineal_tears_ccs_v3.pdf">around 5-7%</a> in Victoria for first-time mothers, the increase of 21% raises the overall likelihood to around 6–8.5%. It’s a modest rise that will bother some, but not others. </p>
<p>Still, women deserve to be given this information so they can judge for themselves whether it worries them enough to ask for a repeat caesarean, or try for a vaginal birth.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="pregnant woman in waiting room" src="https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442432/original/file-20220125-23-f3cuam.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Birth counselling should fully explain the risks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-courses-expectant-mothers-1185645562">Shutterstock</a></span>
</figcaption>
</figure>
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<strong>
Read more:
<a href="https://theconversation.com/mothers-need-better-care-to-reduce-post-traumatic-stress-after-childbirth-12272">Mothers need better care to reduce post-traumatic stress after childbirth</a>
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<p>Counselling is not just about cautioning women of the risks. As midwives and obstetricians, we talk with these women about what will happen when they go into labour, when to come into hospital, and what their chance (and definition) of “successful” vaginal birth might be. </p>
<p>We also mention the most enticing advantage for those whose destiny is an uncomplicated vaginal birth – they sidestep another caesar. Often, this means a <a href="https://pubmed.ncbi.nlm.nih.gov/17181678/">shorter recovery time</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/23186385/">improved likelihood of breastfeeding</a>.</p>
<p>After these discussions, some women will feel the very small risk of serious vaginal trauma (or <a href="https://doi.org/10.1371/journal.pmed.1001184">uterine rupture</a>) is one well worth taking and opt to try for a vaginal birth. Others will opt for the certainty of a repeat caesarean.</p>
<p>Women deserve full support in their birth choices. And they deserve to be fully informed about possible risks. It’s time we broaden our discussions with women planning a vaginal birth after caesarean section to include the increased risk of vaginal birth trauma.</p><img src="https://counter.theconversation.com/content/173249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthea Lindquist receives salary and project funding from the National Health and Medical Research Council. Her current funding (Ideas grant funding) is not related to this project.</span></em></p><p class="fine-print"><em><span>Stephen Tong receives salary and grant funding from the National Health and Medical Research Council of Australia (NHMRC). His NHMRC funding is not related to this project (aside from salary support). Stephen authored The Birth Book and he receives royalties from sales.</span></em></p>Women deserve to know all the risks and be supported in their birth choices.Anthea Lindquist, Obstetrician and Perinatal Epidemiologist, The University of MelbourneStephen Tong, Professor of Obstetrics and Gynaecology, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1318932020-05-28T20:00:56Z2020-05-28T20:00:56ZGroup B strep and having a baby: what pregnant women need to know<figure><img src="https://images.theconversation.com/files/337798/original/file-20200527-106828-ya58sr.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5661%2C3760&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Group B streptococcal (GBS) is a common bacteria that likes to live in the human gut and migrate down the rectum, vagina and sometimes to the urinary tract. Not everyone has GBS but even if you do, you might not know it; it can cause illnesses in people of all ages and sex, but most of the time it doesn’t.</p>
<p>One group at particular risk of GBS, however, is newborn babies, who may pick up GBS from their mother’s vaginal tract during childbirth. For newborns, GBS is a <a href="https://www.ncbi.nlm.nih.gov/pubmed/1749691">major cause</a> of meningitis (infection of the lining of the brain and spinal cord), sepsis (blood infection) and pneumonia (lung infection). </p>
<p><a href="https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-gbs-pregnancy-newborn.pdf">Most early onset GBS disease</a> (90%) occurs in the first 24 hours and up to a week following birth. It affects around 1 in 2,000 babies. Some become very sick and, while rare, around 1 in 17,000 die of it. </p>
<p>Around 10-30% of pregnant women are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4074726/">colonised</a> with GBS, meaning the bacteria live in or on the woman’s body without her necessarily feeling unwell.</p>
<p>It was once standard procedure in many Australian hospitals to administer intravenous antibiotics to such women early in labour in an effort to reduce risk to newborn babies. </p>
<p>However, other countries are pursing different approaches to attempt to reduce the disruption early exposure to antibiotics can cause to the newborn’s microbiome.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-while-pregnant-or-giving-birth-heres-what-you-need-to-know-133619">Coronavirus while pregnant or giving birth: here's what you need to know</a>
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</p>
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<h2>Two approaches to screening pregnant women for GBS</h2>
<p>There are two approaches to GBS screening in pregnancy: universal screening and a risk-based strategy.</p>
<p>All women who are pregnant are recommended to have a urine test (early in pregnancy) which may pick up GBS. Universal screening involves taking a swab of the pregnant woman’s vagina and around the anus (which women can do themselves) when they’re around 36 weeks pregnant. Under the universal approach, all women who test positive to GBS are recommended to have intravenous antibiotics during labour to reduce the risk of the baby developing a GBS infection soon after birth. </p>
<p>A risk-based strategy means only giving antibiotics to women who test positive to GBS or have other high risk factors such as:</p>
<ul>
<li>the labour that starts before 37 weeks </li>
<li>the baby has a low birth weight</li>
<li>membranes (water surrounding the baby) are broken for longer than 18-24 hours </li>
<li>the mother has had a baby previously sick with GBS</li>
<li>the mother has a high temperature during labour.</li>
</ul>
<p>So which approach delivers better outcomes? Unfortunately, it’s not yet possible to answer that question conclusively. </p>
<p>In the <a href="https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-gbs-pregnancy-newborn-booklet.pdf">United Kingdom</a>, Denmark, Netherlands and New Zealand universal screening is <em>not</em> recommended. </p>
<p>In the <a href="https://www.sciencedirect.com/science/article/pii/S1871519213004034?via%3Dihub">United States</a> universal screening for GBS <em>is</em> recommended.</p>
<p>In <a href="https://www.health.gov.au/resources/pregnancy-care-guidelines/part-f-routine-maternal-health-tests/group-b-streptococcus">Australia</a> it’s up to health providers and hospitals to make a decision with women on whether to test. But this can also be very confusing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337845/original/file-20200527-141299-u4sr77.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">For a newborn baby, the first super dose of microbes comes during the birth through the vagina.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>GBS can come and go</h2>
<p>The problem is that GBS can come and go. It may be present when a woman is screened late in pregnancy but not at the time of birth. And confirmed GBS sepsis (blood infection) cases in babies can occur in mothers who tested negative for GBS when screened <a href="https://pubmed.ncbi.nlm.nih.gov/20569813/">earlier in pregnancy</a>.</p>
<p>In short: sometimes GBS testing has meant women (and their newborns) who don’t need antibiotics are getting them, while others who might benefit from antibiotics are missing out. </p>
<p>However, new rapid GBS screening takes around two hours to get the result, meaning women can be tested when they go into labour or their waters break. Unfortunately, these rapid tests are not yet available in all Australian hospitals.</p>
<h2>What does the evidence say about antibiotics for GBS?</h2>
<p>If antibiotics are given more than <a href="https://www.ncbi.nlm.nih.gov/pubmed/23219695">four hours</a> before the birth, it prevents GBS in the baby in 91% of cases.</p>
<p>But antibiotics prevent GBS in babies in <a href="https://www.ncbi.nlm.nih.gov/pubmed/23635620">less than 50%</a> of cases if given fewer than four hours before the birth. </p>
<p>And antibiotics during labour make no difference when it comes to reducing late-onset GBS disease (one week or more following birth).</p>
<p><a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007467.pub4/full">A review</a> of four randomised controlled trials involving 852 women found giving antibiotics to women who tested positive for GBS reduces the incidence of early onset GBS disease in babies, though not death from GBS infection or other bacterial infections.</p>
<p>However, there were some problems with these studies, including small numbers and poor reporting which makes these results unreliable.</p>
<p>This means automatically giving antibiotics to all women during labour is not supported by conclusive high-level evidence; however, it is widely recommended if GBS has been found.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337846/original/file-20200527-141291-1uoatx1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As the baby passes through the vagina, it is coated in and ingests protective bacteria.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What about the impact of antibiotics on the microbiome?</h2>
<p>For a newborn baby, the first super dose of microbes comes during the birth through the vagina, which contains around 200-300 types of bacteria.</p>
<p>These bacteria help seed the new <a href="https://www.sciencedaily.com/releases/2019/09/190918131447.htm">baby’s microbiome</a>, shaping its health and setting up an effective defence shield for infections. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/">microbiome of the vagina</a> changes through pregnancy. Halfway through pregnancy, hormonal shifts begin to stockpile glycogen (bacteria’s favourite food). As the bacteria turn this glycogen into lactic acid the PH level of the vagina lowers (more acid like) and this discourages harmful bacteria like GBS from growing. </p>
<p>As the baby passes through the vagina, it is coated in and ingests this protective bacteria (this process doesn’t occur with caesarean section). When the baby breastfeeds, they ingest components that are only found in breastmilk that feed the good bacteria and <a href="https://www.frontiersin.org/articles/10.3389/fped.2019.00047/full">protect the baby</a>.</p>
<p>Disturbance of this vulnerable early seeding of the microbiome with antibiotic use during labour and birth for GBS alter <a href="https://fn.bmj.com/content/105/2/201.abstract">the balance of microbes</a> in the baby’s intestines. </p>
<p>Several <a href="https://theconversation.com/antibiotics-before-birth-and-in-early-life-can-affect-long-term-health-97778">inflammatory conditions</a>, including obesity, have also been linked to this. </p>
<p>Weighing all this information up means a clear recommended pathway for GBS detection and treatment still evades us.</p>
<p>The most important thing for new parents to know is how to look out for an unwell baby and get help quickly. Signs of GBS infection include:</p>
<ul>
<li><p>temperature that’s too high or low (get a thermometer)</p></li>
<li><p>poor feeding</p></li>
<li><p>irritability</p></li>
<li><p>sleeping more than normal or not moving much</p></li>
<li><p>rapid or noisy breathing (grunting or moaning)</p></li>
<li><p>skin colour changes (including looking blotchy)</p></li>
<li><p>any significant change in behaviour that does not resolve.</p></li>
</ul>
<p>The quicker the treatment, the better the outcome. Breastfeeding can’t pass GBS infection to your baby and, in fact, is really important to help protect your baby from infections.</p>
<h2>The MothersBabies Study</h2>
<p>Our <a href="https://microbiome.org.au/mothersbabies-study-opens-additional-sites/">MothersBabies Study</a> is investigating how the microbiome affects a woman’s health before pregnancy, during pregnancy, and in the first year of their child’s life.</p>
<p>This study can’t be conducted without the help of the community, so please get in touch if you want to know more or are interested in being included. You just need to be living in NSW and planning to get pregnant in the next 12 months. Email <a href="mailto:mothersbabies@unsw.edu.au">mothersbabies@unsw.edu.au</a> to register your interest or find out more.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-with-a-baby-what-you-need-to-know-to-prepare-and-respond-133078">Coronavirus with a baby: what you need to know to prepare and respond</a>
</strong>
</em>
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<p><em>Correction: This article was corrected to change “A risk-based strategy means only giving antibiotics to women who test positive to GBS and have other high risk factors” to “A risk-based strategy means only giving antibiotics to women who test positive to GBS or have other high risk factors such as”. We also clarified when the urine test is done and that confirmed GBS sepsis can occur in babies in mothers who tested negative for GBS earlier in pregnancy.</em></p><img src="https://counter.theconversation.com/content/131893/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen AM receives funding from ARC and NHMRC. </span></em></p><p class="fine-print"><em><span>Emad El-Omar receives funding from MRFF and the Australian government.</span></em></p><p class="fine-print"><em><span>Naomi Strout is the Project Manager for the MothersBabies Study at UNSW's Microbiome Research Centre. The study received funding from the Australian Government's Medical Research Future Fund. </span></em></p>Newborn babies can pick up GBS from their mother’s vaginal tract during childbirth.Hannah Dahlen, Professor of Midwifery, Associate Dean Research and HDR, Midwifery Discipline Leader, Western Sydney UniversityEmad El-Omar, Professor of Medicine, UNSW SydneyNaomi Strout, Researcher, Microbiome Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1181402019-06-12T11:05:00Z2019-06-12T11:05:00ZNumber of women steered towards repeat caesareans is much higher than necessary<figure><img src="https://images.theconversation.com/files/278287/original/file-20190606-97989-1bijs58.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant with possibilities. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/tEz8JU1j-00">Mustafa Omar</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>As many as one in four women in the UK <a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1016/j.ijgo.2013.12.013">now give birth</a> by caesarean section, the vast majority of them carried out by choice. The overall number has more than trebled in the last 40 years.</p>
<p>While it is true that birthing outcomes for women and babies have improved over this period, there is no evidence that this is a direct result of the increase in caesareans. While women should be able to choose how they give birth, this is not always clearly presented to them by doctors or midwives. This could undermine the ability of these mothers to choose whichever option is right for them, whether a caesarean or a vaginal birth. </p>
<p>Something like four in five caesareans are planned as opposed to emergency, and many are women who have already given birth the same way in a previous pregnancy. In many hospitals in the UK, this means that the proportion of women who have vaginal births after previously having caesareans is low. </p>
<p>This is despite the fact that vaginal births after caesareans <a href="https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/">are successful</a> in as many as 76% of cases – in situations when these births are not working out, normally it simply means that the mother needs to give birth by another caesarean instead. So what’s the problem?</p>
<h2>Reluctant doctors</h2>
<p>The policy and professional guidelines in the UK <a href="https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/">say that</a> clinicians should involve women in these birthing decisions. Clinicians’ professional bodies <a href="https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg45/">recognise</a> that it is safe for most women to have vaginal births after caesareans, yet the quality of information they receive varies, and there is <a href="https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1016/j.ijgo.2013.12.013">evidence that</a> some clinicians are conservative about supporting women to let nature take its course.</p>
<p>Though many parts of the UK <a href="https://www.nice.org.uk/guidance/cg132?unlid=9290976632016213173944">have established</a> “pathways of care” which aim to improve the access and consistency of the information, pregnant women still don’t always receive full and unbiased advice. It has been <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-12-85">described</a> as a “fog” of conflicting opinions and advice, based on the clinician’s experience or personal preference rather than scientific evidence.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278289/original/file-20190606-98003-17poll6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘Your best option …’</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pregnant-woman-doctor-hospital-397630249?src=QNhWlCwzzeSvbzgASYphAA-1-2&studio=1">Africa Studio</a></span>
</figcaption>
</figure>
<p>This may be the result of obstetricians with less experience in giving the relevant counselling – or who lack the confidence to manage the labour of women who opt for a natural birth, which may be more complicated. Part of the problem is that the prospects for a successful vaginal birth in these circumstances varies from woman to woman, and there is no UK model available that accurately predicts which women are likely to be more successful. </p>
<p>While this exists in other countries, such as <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.12605">the Netherlands</a>, you can’t just cut and paste another national model because women vary from country to country in everything from ethnicity to the state of their health. To ensure that UK women can properly take part in a shared decision-making process, with information that is tailored to them, we therefore need to develop a model based on data collected within the country. </p>
<h2>The UK study</h2>
<p>I have been involved in <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2226-6">a study</a> aimed at identifying predictive characteristics that could inform such a model. We used detailed clinical information for over 1,600 women who had attempted vaginal births after a previous caesarean. This is the largest UK study using consistently detailed data, and also includes about three times more women than any European studies. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1129&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1129&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278290/original/file-20190606-98022-1q8icr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1129&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Counting down.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/6CVObBqPkTY">Mustafa Omar</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>In keeping <a href="https://www.ncbi.nlm.nih.gov/pubmed/23921867">with</a> previous <a href="https://www.ncbi.nlm.nih.gov/pubmed/17466668">studies</a>, we found that factors that made such women more likely to have a successful vaginal birth included: not being overweight; having previously had a caesarean because the baby was in breech position; or having previously had a vaginal birth as well as a caesarean. Importantly, however, we also found that a previous caesarean in the second stage of labour – when the cervix has completely opened and the woman has started pushing – was strongly associated with a successful vaginal birth for a future pregnancy. </p>
<p>It is hoped that these findings will encourage clinicians to take the evidence into account when offering advice. Our next step is to test the same findings on a larger number of women using data from across Scotland – this first study concentrated on Scottish women from one hospital. In time, this should help develop a clinical tool that will support women to make more informed choices about how they give birth – hopefully making more women confident about their ability to give birth vaginally, if that is what they choose to do.</p><img src="https://counter.theconversation.com/content/118140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tracy Humphrey receives funding from Chief Scientist Office (Scotland), Burdett Trust, Global Research Challenge Fund, Scottish Government International Development Fund and NHS Education for Scotland.</span></em></p>Professional bodies say that vaginal births after caesareans are safe and usually successful. So why do doctors often recommend that women go back under the knife?Tracy Humphrey, Dean of Health and Social Care, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/934262018-03-26T04:21:52Z2018-03-26T04:21:52ZHow birth interventions affect babies’ health in the short and long term<figure><img src="https://images.theconversation.com/files/211890/original/file-20180326-54872-1rpft11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Intervention will sometimes be required in childbirth, but should only occur when medically necessary.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sofia-bulgariajanuary19-2018-woman-waits-give-1028955100?src=wWQCjkdxDSFNlSpANfJEmw-1-15">Circlephoto/Shutterstock</a></span></figcaption></figure><p>Medical and surgical intervention during birth continues to rise in much of the world. Nearly <a href="https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies-2015-in-brief/contents/table-of-contents">one in three women</a> who give birth in Australia have a caesarean section and around 50% have their labour induced and/or augmented (sped up with synthetic hormones). </p>
<p>Our new research, published today in the journal <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/birt.12348">Birth</a>, found babies born via medical or surgical intervention were at increased risk of health problems. These include short-term concerns such as jaundice and feeding problems, and longer-term illnesses such as diabetes, respiratory infections and eczema. </p>
<p>Intervention will sometimes be required in childbirth, but should only occur when medically necessary. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/birth-intervention-and-harm-more-likely-in-private-hospitals-26801">Birth intervention – and harm – more likely in private hospitals</a>
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<h2>What did we find?</h2>
<p>Our international team, based in five countries, analysed data from nearly 500,000 healthy, low-risk women who gave birth in New South Wales between 2000 and 2013, and their children. We looked at their children’s health in the first 28 days and up to five years of age. </p>
<p>We then compared the health outcomes of children whose mothers went into labour spontaneously and gave birth vaginally, with those who were born via medical or surgical intervention.</p>
<p>Medical intervention is when labour is induced using synthetic hormones that start labour and/or augment labour by producing stronger contractions. </p>
<p>Surgical intervention includes caesarean section and instrumental delivery using forceps or vacuum. This is where metal tongs or a plastic suction cap are placed around or on the baby’s head to enable it to be pulled through the vagina.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">From barber surgeons to car mechanics: the technologies of vaginal birth</a>
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<p>We found:</p>
<ul>
<li><p>Babies who experienced an <a href="https://theconversation.com/from-barber-surgeons-to-car-mechanics-the-technologies-of-vaginal-birth-20474">instrumental birth</a> (forceps or vacuum) following induction or augmentation had the highest risk of jaundice and feeding problems needing treatment in the first 28 days</p></li>
<li><p>Babies born by caesarean section had higher rates of being cold and needing treatment in the hospital for this compared to babies born via vaginal birth</p></li>
<li><p>Children born by emergency caesarean section had the highest rates of metabolic disorders (such as diabetes and obesity) by five years of age</p></li>
<li><p>Rates of respiratory infections, such as pneumonia and bronchitis, metabolic disorders, and eczema were higher among children who experienced any form of birth intervention than those born vaginally.</p></li>
</ul>
<p>Our study adds to the <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002494">growing scientific evidence</a> that children born by spontaneous vaginal birth have fewer short- and long-term health problems. </p>
<p>The findings hold even when you take into account the reason that might pre-empt the intervention, such as induction or caesarean section because the mother has diabetes or high blood pressure. We removed all women with such risk factors from the study.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=477&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=477&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211893/original/file-20180326-54878-3vcbnl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=477&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rates of infections are higher among babies who experienced any intervention.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-baby-sleeping-hospital-bed-1050762434?src=lp8fCCv3FEMsvu99QAfhlA-1-51">kipgodi/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Why the increased risk?</h2>
<p>This study showed an association between common forms of medical and surgical intervention and certain health outcomes for the child. It didn’t find one thing caused the other. But there are some obvious reasons for some of the links. </p>
<p>Forceps and vacuum birth, for instance, can cause bleeding and bruising in the baby’s scalp. These blood cells break down, releasing bilirubin that causes the skin to look yellow, which signals jaundice. </p>
<p>Babies born by caesarean section are more likely to be cold because the operating theatre is cold. Despite recommendations for the baby to be placed on the mother’s chest as soon as possible, this doesn’t always happen. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/women-need-more-freedom-during-labour-not-a-medicalised-birth-script-to-follow-92079">Women need more freedom during labour, not a medicalised birth script to follow</a>
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<hr>
<p>Reasons for the increased risk of longer-term problems are much less clear, but there are a couple of interesting <a href="https://theconversation.com/can-caesarean-sections-increase-susceptibility-to-disease-12334">hypotheses</a>. </p>
<p>The first key theory is <a href="http://science.sciencemag.org/content/330/6004/611">based on epigenentics</a>: that life events affect how genes function and are passed on to the next generation. </p>
<p>Labor and birth exert a positive form of stress on the fetus, which impacts on the genes responsible for fighting off bugs, weight regulation and suppressing tumours. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23414680?dopt=Abstract">Too little stress</a> (no labour and elective caesarean section) or too much stress (induced/augmented labour and instrumental birth) could impact the expression of these genes.</p>
<p>The second key theory is the <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0768-9">extended hygiene hypothesis</a>. This suggests that vaginal birth provides an <a href="https://www.theguardian.com/lifeandstyle/2017/nov/06/microbiome-gut-health-digestive-system-genes-happiness">important opportunity</a> to pass gut bacteria from mother to baby to produce a healthy microbiome and protect us from illness. </p>
<p>If we have an unhealthy microbiome, we may be more vulnerable to infections, allergies, diabetes and obesity.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gut-instinct-how-the-way-youre-born-and-fed-affect-your-immune-system-65104">Gut instinct: how the way you're born and fed affect your immune system</a>
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<hr>
<h2>How to reduce unnecessary birth intervention</h2>
<p>Recently released <a href="http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf">guidelines from the World Health Organisation</a> (WHO) recommend ways to reduce unnecessary intervention by encouraging evidence-based clinical care. Among the recommendations are three that can be applied in Australia:</p>
<ol>
<li><p>Women should have continuity of care, where they see the <a href="http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD003766.pub6/full">same health practitioner</a> throughout pregnancy, during the birth, and in the postnatal period. This reduces the risk of unnecessary interventions.</p></li>
<li><p>Don’t intervene too early. Women progress much slower in labour than we previously thought. For 70 years, clinicians believed the cervix should dilate by 1 cm per hour. If the cervix was slower to dilate, intervention was initiated because labour was thought to have slowed. We now know labour progresses <a href="https://www.ncbi.nlm.nih.gov/pubmed/28892266">more slowly</a>.</p></li>
<li><p>Don’t use <a href="http://www.cochrane.org/CD006066/PREG_continuous-cardiotocography-ctg-form-electronic-fetal-monitoring-efm-fetal-assessment-during-labour">continuous electronic monitoring (CTG)</a> to monitor the baby, unless there are significant risk factors. Instead, listen in regularly with a small, hand-held monitor. Continuous monitoring increases intervention rates for low-risk women and healthy babies without improving outcomes for babies.</p></li>
</ol>
<p>Introducing a more evidence-based approach to care during labour and birth can increase the rates of spontaneous vaginal birth and reduce unnecessary intervention.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/211894/original/file-20180326-54884-mfssc1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Child birth guidelines should be evidence based to avoid unnecessary intervention.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-infant-baby-feeding-mother-breast-1052320577?src=A1-WJ7SzoEV51-j7osNcYg-1-22">GOLFX/Shutterstock</a></span>
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<h2>When intervention is necessary</h2>
<p>A certain level of intervention during childbirth improves outcomes for women and babies. But the <a href="http://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf?sequence=1">World Health Organisation recommends</a> the caesarean rate should be under 15%. </p>
<p>Babies may need to be induced when they are small and not growing well, or if they are overdue (beyond 41-42 weeks). </p>
<p>Caesareans may be necessary before labour even starts, such as when the placenta is lying across the cervix (placenta praevia), or when labour is in progress, if the baby gets distressed.</p>
<p>If you need to have your labour induced or augmented, or require an instrumental birth or a caesarean section due to complications, there are some things to help modify the long-term effect on your child. Seek uninterrupted <a href="https://www.ncbi.nlm.nih.gov/pubmed/24720501">skin-to-skin</a> contact after the birth and <a href="http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/">exclusively breastfeed</a>, if you can. </p>
<p>It is important for women and their partners to have all the information about both short- and long-term effects of intervention to make truly informed decisions about care during pregnancy and birth.</p><img src="https://counter.theconversation.com/content/93426/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Dahlen receives funding from NHMRC and ARC. She is affiliated with the Australian College of Midwives</span></em></p><p class="fine-print"><em><span>Lilian Peters does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our study found babies born via medical or surgical intervention were at increased risk of health problems, from jaundice and feeding issues, to diabetes, respiratory infections and eczema.Hannah Dahlen, Professor of Midwifery, Western Sydney UniversityLilian Peters, Post Doctoral Research Fellow, Vrije Universiteit AmsterdamLicensed as Creative Commons – attribution, no derivatives.