The Bumpologist

Bumpology was originally a column for New Scientist. Previous columns

Hypnobirthing doesn’t reduce labour pain

Giving birth needn’t be painful, if you just banish fear. So goes the mantra of hypnobirthing instructors, who tell you to “embrace each gentle birthing wave” and imagine yourself in a beautiful garden, plucking fruit from a bowl, or soaring high in a hot air balloon and casting your anxiety overboard.

It’s an attractive idea – even Kate Middleton is rumoured to be considering giving it a try – but does it really work? Up until now, the only studies to investigate hypnobirthing have been relatively small and not particularly well designed, making it difficult to determine whether it is any good or not.

But a new study published in the British Journal of Obstetrics and Gynecology may finally provide an answer. Anette Werner at Aarhus University in Denmark and her colleagues took 1222 healthy pregnant women expecting their first child, and randomly assigned a third of them to receive three hours of instruction in self-hypnosis, plus audio-recordings to help them put themselves under; another third were taught general relaxation and mindfulness techniques; while the remaining third received no training.

If hypnobirthing is effective, the researchers reasoned, then fewer women would request epidural pain relief and they would rate their labour as less painful overall. Unfortunately, that’s not what happened. There was no difference between the three groups in terms of their epidural use, or in their self-assessment of pain.

This study doesn’t mean that hypnobirthing isn’t effective for a subset of women – maybe if the researchers had only selected women who believed from the outset that hypnosis would work, they would have got a different result. But then, such women may have been biased in how they reported the experience. The point about this study is that the women were chosen at random.

It’s also true that labour varies massively between individuals, and even between different pregnancies. But if this is your first baby, you have no idea how your body will react to labour or how things will progress.

My own experience of hypnobirthing was that it was great for reducing my anxiety about birth in the run-up to labour, and even useful in the early stages, before the contractions got too intense. However, I felt that its focus on describing contractions as surges, and pain as pressure left me totally underprepared for just how intense the “pressure” actually was. As a result I panicked, and I suspect that this undid any good that hypnobirthing might have achieved in terms of relaxing into labour. Maybe it would have been more useful second time around, when my eyes would have been more open to what I could expect – but I’ll never know: I had to have a c-section as a result of complications from the first birth.

My advice to women considering self-hypnosis would be to by all means take those hypnobirthing classes (if you can afford them), but keep your mind open to other forms of pain relief and to the idea that things may not go as smoothly as your teacher might suggest. And know that if you don’t achieve a “perfect” natural birth, then you’re perfectly normal and you’ve still done a fantastic job in producing a healthy baby.

Pouring cold water on baby formula

“How do you make a (baby) bottle in middle of night,” began a thread on Mumsnet’s forum earlier this month. “All that boiling the kettle and letting it cool malarkey is no good at 3am.”

I’ve been pondering a similar conundrum, as I’ve started introducing the odd bottle of formula to my breastfed baby’s diet (usually when my 4-month–old and 2-year-old are simultaneously clamouring for their dinner and I don’t have time to sit and breastfeed). A fellow journalist also just wrote to me asking if it was really necessary to add recently boiled water to powdered baby formula, as UK formula manufacturers generally recommend.

I’ll admit that I’ve been slightly sceptical of this advice ever since travelling to North America with an 8-month-old two years ago. Over there, the formula boxes said to add cold water to the baby formula – but to use it straight away, not store it in the fridge for later.

It’s all very confusing. Is it bacteria living in the milk powder or the water that’s the issue? Or is it that freshly made formula is ok, but stored formula is problematic because the bacteria might have time to grow?

To try and get to the bottom of this I contacted the World Health Organisation (WHO), which published new guidelines on preparing infant formula in 2007.

The WHO says their main concern is a bacterium called Enterobacter sakazakii, which is relatively rare (it is estimated to affect one in 100,000 babies), but when it does strike, it is deadly in 20-50% of cases. During an outbreak in France in 2004, nine babies fell ill (most of them premature babies), and two died. Powdered baby formula was thought to be the cause. Contamination with Salmonella enterica (a bacterium that causes serious food poisoning) is also a worry.

Here’s what Peter Karim Ben Embarek of the WHO told me: “What is not commonly known is that formula powder is not a sterile product. Harmful bacteria like C.sakazakii could be present in the powder and multiply in the prepared bottled if left for too long. The use of hot water is to kill cells of C. sakazakii that maybe present in the infant formula powder.”

Although bacteria in dried milk powder won’t grow, they can survive for up to a year. And once water is added to the powder they will start to grow quickly.

Ben Embarek and his colleagues have done experiments to replicate pretty much every way of making up a bottle of formula milk (adding cold water; lukewarm water; hot water; storing bottles in the fridge; outside a fridge, etc).

They found that the two best ways of reducing the risk of infection are:

  1. Preparing formula with water hotter than 70 ⁰C (this kills the bugs), and then cooling it by standing the bottle in cold water.
  2. Once the formula has been prepared, drinking it ASAP

That doesn’t mean you can’t prepare a batch of formula in advance, but you do need to refrigerate it (and it would be safer to make a fresh bottle every time). Refrigerated bottles can be stored for up to 24 hours. You can also transport formula in a cool bag, but it should be used within 2 hours.

The WHO guidelines also say that in emergencies you could use tap water at room temperature (assuming the tap water is safe to drink), but you’d have to feed it to your baby immediately.

I used formula for my older daughter once she turned six months, and my strategy when out and about was to take some powdered formula in a sterile container and a thermos of boiling water so that I could make up a batch of formula from scratch. It sounds like this could still be a sensible option, provided the water stays piping hot (above 70 ⁰C). I also have a couple of those Tommee Tipee cool bags to keep milk cold.

But how do you reheat your formula if it’s been pre-prepared and stored in a fridge? The standard advice is to stand the bottle in a bowl of hot water, periodically swirling it around. This is time consuming – so many parents will resort to the microwave. The WHO says this is a bad idea: microwaves heat unevenly, so hotspots may appear that could scald a baby’s mouth.

However, research conducted in 1992 concluded that microwave ovens can be used to heat baby formula if some precautions are taken:

  • Heat only 4oz (120ml) or more
  • Only heat refrigerated formula
  • Always stand the bottle up and leave uncovered so heat can escape
  • Heat 4oz bottles for no more than 30 secs (these tests were done using a 700-W oven)
  • Heat 8oz bottles for no more than 45 seconds
  • Replace nipple and invert bottle ten times (to disperse any hot spots)
  • Formula should be cool to the touch
  • Always test formula by shaking some onto the top of the hand, or the tongue

Does the NCT tell women the truth about birth?

Yesterday, I accidentally opened the floodgates to a mass outpouring of criticism of the National Childbirth Trust (NCT), when I appeared on Radio 4’s Today programme describing my experiences of NCT classes. With me, was the NCT’s chief executive Belinda Phipps, who defended the organisation.

Almost immediately, TV presenter Kirstie Allsopp tweeted: ‘Turn to BBC Radio 4 for talk of a book about all the absurd myths surrounding pregnancy & birth. More NCT b******* as usual though. Lots of people have good NCT experiences, but many don’t. This is a very politicised, dogmatic and in my experience, scary organisation.’

Allsopp’s comments prompted a flurry of Tweets from ex-NCT class attendees, some positive, but many negative, ultimately resulting in a story in the Daily Mail.

Sadly Today only gave us three minutes on air, but I had a much longer chat with Phipps beforehand and I thought people might be interested to hear what she said to me.

When I was pregnant with my first daughter, I attended NCT classes, like so many pregnant women do, with the primary goal of making some new friends. I also expected to get accurate, impartial advice about birth and the choices available to me.

I’ll admit that I was completely ignorant about what birth might entail. Obviously I’d heard that it was painful, but I’d also attended hypnobirthing classes where I’d been told that women could give birth as easily as sheep or cows if only they banished fear (yes, I realise this sounds ridiculous now ).

Upon hearing that I’d been doing hypnobirthing, my NCT teacher suggested I consider a home birth, which I declined. Instead, I planned to go to a midwife-led home-from-home centre in London, because that sounded rather cosy.

In our NCT classes, we learned about the various drug options available to us – in fact we had to go off and research them for ourselves, then present back to the class. But our teacher also seemed to make her own thoughts on pain relief clear, when several weeks into the course, we started hearing this phrase: “a spiral of medical intervention”.

Through a series of role-plays, we learned that if we requested an epidural (which involves inserting a big needle into your spine) to numb the pain, we’d end up flat on our backs, strapped up to an array of monitors and machines that go beep. Not only would this quash any hopes of a beautiful water-birth, we’d be more likely to need a c-section or a birth involving forceps which might make us tear. This was terrifying. Not only am I afraid of needles, I was terrified of tearing, and our teacher had also told us that a c-section would make breastfeeding difficult; would make it hard to bond with our babies; and would take weeks to recover from.

The overriding impression I was left with was that birth is something women can control, that doctors aren’t to be trusted, and that if I did end up requesting an epidural or needing a c-section I would have failed in some way.

Reading many of the comments that Allsopps’ Tweet provoked, I know I’m not alone in this. In a previous blog, I also described research suggesting that women who go into labour wanting a natural birth and end up having an epidural often feel profoundly disappointed and guilty.

When I was researching my book, Bumpology, I revisited many of the things I’d heard about the risks associated with c-sections, induction and epidurals and discovered that many were overblown, based on flaky scientific research, or untrue.

When I put all of this to Belinda Phipps, she largely agreed, and pointed out that the NCT’s website has a whole section devoted to evidence-based guidelines, which I have read (and occasionally even reference in my book) . They are clear and well researched. The point is I didn’t know about these when I was pregnant, and our NCT teacher certainly never told us about them (Phipps says a few of these guidelines are now handed out in classes for parents to read at their leisure).

I wonder how there can be such a disconnection between what the NCT as an organisation says, and what some of its teachers preach. I’ve even come across an NCT document which advises teachers on the kind of messages they should convey. They include telling women:

“Do what you can to minimise complications developing, but do not feel personally responsible for achieving the ‘perfect birth’. Childbirth is unpredictable and often does not go according to a mother’s wishes. Prepare yourself for the kind of birth you would like and for possible deviations from your ideal.”

Phipps’ defence is that although all NCT teachers have to sit a diploma and are periodically checked, they are only human and they have their own beliefs. Fine, but if they are teaching under the NCT’s name, perhaps the NCT should keep them on a tighter rein.

There are also things about “natural” birth that my NCT teacher didn’t tell me, but I wish she had:

  • That tearing during a “natural” birth is extremely common (85% of women tear and more than a third need stitches); that it’s not that bad, but that you really must take care of the wound and watch for any signs of infection (swelling, heat, discharge) and INSIST on seeing a doctor if you suspect one.
  • That you may get so constipated after a natural birth that the lining of your bottom may tear, so you need to drink, drink, drink!
  • That a lot of women get stuck in the early stages of labour – sometimes for days – and that it is excruciating and exhausting. And that an epidural can bring enormous relief and even speed up labour in these circumstances.
  • That although 36% of women anticipate suffering extreme pain during labour, 65% report experiencing it

Phipps rightly pointed out that there is a lot to cram into the 16 or so hours of tuition that you get on an NCT course. But it wouldn’t take much to tell parents about some of these realities – even hand them a brown paper envelope “to be opened once you have your baby”, advising women on the first difficult days after birth.

Phipps also told me that parents can always call their teacher between classes if they have any extra questions – but how can expectant parents really know what they should be asking?

Finally, Phipps says that women can complain if they feel unhappy about what an NCT teacher has told them, and that she will act upon it. But if you don’t realise that what your NCT teacher has told you may be distorted or unbalanced, how can you know to complain? Also, calling the NCT is possibly the last thing you feel like doing when you’ve just given birth. You have enough on your plate.

On balance, the NCT does a huge amount of good, and without them I never would have met some of my closest friends. But they shouldn’t ignore those who feel let down – or that they have let themselves down – as a result of what their NCT teacher has said. It’s time for the NCT to listen to the criticisms of, not only famous mums like Kirstie Allsopp, but to the hundreds of parents who have responded to her comments with horror stories of their own. Its leadership must take action to ensure that the NCT’s central, evidence-based message isn’t diluted by the personal beliefs of teachers, which are at odds with the best-available scientific research.

Mulled wine? But you’re breastfeeding…

A woman sits down in a pub with a large glass of wine and a newborn baby, then pulls up her top and starts breastfeeding. Would you do a double-take? A few years ago, I was out celebrating a friend’s birthday (with baby in tow), when a hairy man in his fifties wearing a grubby t-shirt strode up to me and told me that I was disgusting. I’m not sure if he was referring to my swollen breasts, the fact that I was drinking, or that I’d deigned to take a baby into his local pub, but with the current onslaught of Christmas parties, friends have been bombarding me with questions about how much alcohol it’s safe to drink when pregnant or breastfeeding.

I’ll refer any pregnant readers to a column I wrote for New Scientist about alcohol during pregnancy when I was expecting my first baby, but to summarize: it’s a massive grey area, though you’d be hard-pushed to argue that the odd glass of wine is going to cause any harm to your developing baby.

As for anyone who, like me, has just completed nine months of near-abstinence and is relishing the taste of mulled wine (but worries that alcoholic wineshakes might not be so good for their breastfed baby) I have both good news and bad.

The bad news is that alcohol does get into breast milk in roughly the same quantities as it gets into your blood. So if you’re drunk, then yes, that breast milk is boozy too.

The good news is that:

  1. It isn’t stored there, meaning that as your blood alcohol levels fall, so too does the amount of alcohol in your breast milk. There’s no point in pumping and dumping your milk the morning after a night out because you’re worried about its alcohol content (unless it was a REALLY big night out). As a rough guide, it takes about an hour to process and eliminate one unit of alcohol from your body – although it also takes a little while for alcohol to get into your bloodstream after having a drink. This means that drinking your wine while breastfeeding is probably slightly better than drinking it afterwards as there’s more time to eliminate it before the next feed. It also means that if you have three glasses of wine (approximately 6 units) it will take 6-7 hours before your milk will be alcohol-free again.
  2. If you do decide to breastfeed after a few drinks, the amount of alcohol that gets into your baby’s bloodstream will be significantly less than the amount in your blood, because it has to pass through their digestive system first.

So is it wrong to breastfeed if your milk is ever so slightly boozy? In the short-term, drinking alcohol dampens your “let-down” response, meaning your baby gets less milk to drink and will try and compensate by feeding more frequently until it catches up (not great if you have a hangover). Alcoholic milk also seems to affect the quality of babies’ sleep: they fall asleep faster, but sleep for less time overall.

However, there is no strong evidence that drinking while breastfeeding has any long-term health impact on babies’ development – though there is a surprising paucity of research in this area, so no-one really knows for sure. Personally, I don’t worry about breastfeeding if I’ve had a glass of wine or two with dinner, but I would feel uncomfortable about feeding my baby if I’d had a lot to drink, as it stands to reason that very boozy milk probably doesn’t do little babies any good. If I’m planning a big night out, I’ll either express some milk the morning before, or turn to my “emergency formula” supply.

My current dilemma is that I have a friend’s birthday to go to tomorrow night, and a 12-week-old who is going through a growth spurt — there’s literally no excess milk to express. So if you see me in the pub with a glass in one hand and a baby in the other, please raise your glass in solidarity.

Does Kate Middleton’s morning sickness suggest she’s growing a future queen (or queens)?

Poor Kate Middleton has been hospitalised with hyperemesis gravidarum, an extreme form of morning sickness that afflicts around one in 50 pregnant women. The jury is still out on the precise cause of morning sickness, but the most convincing explanation I’ve found is that it’s down to an unfortunate side effect of the same hormone that confirms you’re pregnant in the first place: human chorionic gonadotrophin (HCG) (which is the hormone pregnancy tests detect).

As well as enabling pregnancy to continue by keeping the production of other pregnancy hormones going, HCG has other effects on the body, such as stimulating the thyroid gland, which regulates metabolism. Previous studies have found particularly high levels of thyroid hormones in women with hyperemesis gravidarum, like Kate Middleton. Two other pregnancy hormones, progesterone and oestrogen, also slow down the digestive system, which might also contribute to the queasiness, bloating and heartburn that so often plagues pregnant women.

A common myth is that bad morning sickness suggests you’re carrying a boy, when in fact the opposite is true. In 1999, researchers analysed the records of 8,186 Swedish women suffering from hyperemesis gravidarum and found that just 44.3 per cent of them gave birth to boys, compared to 51.4 per cent of the general population. Researchers have also found higher levels of HCG in women carrying female foetuses and (cue rampant excited royal speculation) twins!

Birth freedom or setting pregnant women up to fail?

I recently heard about a campaign called “the birth I want”, by an inspiring woman called Vicky Garner who believes there should be greater continuity of care during pregnancy and childbirth so that women are better supported in achieving the type of birth they want. While I wholeheartedly agree, I think there’s also something missing from this argument that could improve women’s birth experience – even in the absence of a personal birth attendant: a greater honesty about just what birth entails.

I’m certainly not against natural childbirth. My first daughter was delivered naturally, although I did request an epidural after 31 hours of contractions had failed to make my cervix dilate more than the width of a milk-bottle top (which was dispiriting, to say the least). I think every woman should have the right to choose the type of birth she has, but I also think that it should be an informed choice guided by facts and not the opinions of those around her.

What bothers me is the suggestion by some in the natural childbirth movement that all medical intervention is to be frowned upon, and that labour can be pain-free if you just relax, banish fear, and think positive thoughts. Suggesting that you can choose whether or not to experience pain (unless it’s through the use of drugs), or that you can control whether or not you’ll need a medical procedure like a c-section is in my opinion, simply setting women up to fail.

Before my daughter was born, I attended classes run by the National Childbirth Trust (NCT), which aims to empower women about their birth choices by giving them access to evidence not opinion. The trouble is that my NCT teacher at least, seemed to hold pretty strong opinions about the superiority of natural childbirth, and frightened us with tales of “spirals of medical intervention”. To give an example, we were told that if we requested an epidural, we’d likely end up flat on our backs with heaps of straps and cables hanging off us, and would be more likely to end up having our babies ripped out of us with a pair of forceps, or on the operating table undergoing an emergency caesarean section. Combined with the hypnobirthing course I had attended, I came away with the message that doctors couldn’t be trusted and that since pain is in the eye of the beholder, I could choose not to experience it. My birth plan strongly stated: no epidural!

Unfortunately, for the majority of women, childbirth hurts — a lot. I for one, was unprepared for the level of pain I was going to come up against, and (despite the hypnobirthing training) I panicked, which undoubtably made it worse. A recent study found that while 36% of women anticipated suffering extreme pain during labour, 65% reported experiencing it. Of course there are a lucky few who sail through labour with only mild discomfort, but they are in the minority. When I eventually requested an epidural, I felt guilty, but when my baby then took another eleven hours to make her appearance (42 hours in total), ultimately vindicated.

This isn’t the case for every woman who sets out wanting a natural birth, but ends up needing medical assistance. I recently came across this small study which found that women who went into childbirth with a relaxed and flexible attitude towards what they could expect were more likely to be satisfied with the experience than those who went in with fixed expectations of a certain type of birth, or who focused on specific results like having no medical interventions.

I don’t want to frighten women who are expecting their first child, but I do think there’s a case for greater honesty about what to expect during birth so women are more open-minded to the possibility of drugs, or to the idea that they may need medical assistance at some point. I say this because there’s also evidence that those women who go into birth with their eyes open to the fact that it’s likely to be tough are the ones who are more likely to achieve their goal of a natural birth.

One study of women who planned to have a natural birth found that those who anticipated more pain, who already had children and knew what to expect, and who had higher pain thresholds were more likely to succeed without drugs than first-time mums who had no idea of what to expect. What saddens me about this study is that of those women who had an epidural, 88% said that they thought it made their childbirth unsatisfying, even though it relieved their pain and they gave birth to a healthy baby. Why? Among the reasons given were a sense of failure, and a misplaced concern that an epidural might have harmed their baby somehow. I’ve heard similar anecdotes, including one friend who said she’d feel unable to look her NCT friends in the face if she asked for an epidural.

And epidurals really aren’t as bad as some would have us believe. During the research for my book, Bumpology, I fell pregnant with my second child, and I was forced to revisit much of what I had been told the first time around. This is when I realised that much of what I’d been told wasn’t necessarily true. Take the risk of needing an instrumental delivery (one involving forceps or a ventouse) following an epidural. There is an increased risk, but if you look at the numbers you realise that it’s a small one, and one which has to be weighed against the great relief an epidural can bring. In fact, twenty women would have to undergo an epidural for just one of them to end up with an extra instrumental delivery – and not necessarily because of the epidural drugs, but perhaps because doctors are more ready and willing to get the forceps out if a woman already has an epidural in place. There is no increased risk of a c-section, despite popular belief.

Another midwife friend of mine has just left the labour ward to become a community midwife specialising in home births. I asked her what the majority of pregnant women she sees expect from birth, and she confirmed that many of them come to her with very fixed ideas — be it of a water birth, one completely free from drugs, or one involving alternative ways of managing pain, like hypnotherapy. She tells them: “how can you possibly plan how you’ll react to birth, if you’ve never been through it before.? Let’s just take it as it comes.”

And this is a key reason why we need more midwives to accompany women throughout that bumpy journey into motherhood. For just like a good friend will support your decisions, but let you know if you’re being unreasonable or kidding yourself about sensitive issues (even if you don’t want to hear their advice), a good midwife who has the time to get to know you and your wishes, but who can also counsel you on the true nature of what you’re up against, has got to be a better advocate than a stranger who only meets you once you’re in the throes of labour and has to leave at the end of their 12 hour shift.