What is the human microbiome?

It is the collection of microscopic organisms, also known as microbes, that live in and on our bodies. This collection includes bacteria, viruses, fungi and protozoa and the vast majority of them are harmless to us and most are positively beneficial. We have approximately 100 trillion microbes in our gut. Most of these microbes are bacteria.

Our relationship with our microbes

We have evolved with microbes and we have a mutually beneficial relationship with them. We provide them with a habitat to live in and food for them to eat and in return they provide vital functions for our bodies that we cannot perform ourselves.

How our microbes help us

Our microbes help us regulate our appetite, metabolism and digest our food. They make anti-infective properties, hormones and vitamins, and support the normal functioning of our immune system. They also have a key role in our mental wellbeing. The gut microbiome is now best thought of as being an organ, because of the vital functions it performs.

How we can damage our microbes

Antibiotics and anti-bacterial products can kill off our microbes and leave us with an imbalanced microbiome that can no longer perform all the functions we need it to. Also, a diet that is low in fruit and vegetables does not give our microbes the food they need and this can lead to imbalance in amounts and types of microbes we have and cause inflammation in our gut.

Why is imbalance in the gut microbiome a problem?

The inflammation caused by an imbalanced microbiome is linked to many diseases, such as heart disease, cancer, inflammatory bowel disease, diabetes, obesity, dementia and depression. In pregnancy it is linked to conditions such as preterm birth, gestational diabetes and pre-eclampsia.

How can we help our microbes?

Our lifestyle has an impact on the health of our microbiome. What we do and what we eat and drink impact our microbiome. A diet that is high in fibre and low in processed foods and drinks gives our microbes the food they need to thrive. Having an active lifestyle also benefits our microbiome, it brings them more oxygen and food, enabling them to grow and reproduce. Reducing our stress helps our microbiome by reducing the effects of stress hormones.

Birth preparation classes

Our birth preparation classes look in detail at these issues and support you in making positive changes in your life.

Having a dog and deciding to breed from her was a big decision that changed my life and impacted my professional life as a midwife.  Watching an animal I loved, birth instinctively was incredibly powerful.  I was amazed at her intuitive behaviour and this experience brought realisations to my practice about how women are supported in labour and how that support may not always be the most appropriate or helpful.

My dog role model

My lovely dogs were born 15 years ago.  I midwifed their mum, Ella, and watched Lady and Fergal and their eight siblings enter this world.  I have been reflecting on how much I learned from these lovely animals, over the years and how they impacted me and my professional practice.

Nature and birth

Dogs birth instinctively and do not doubt themselves.  They are not burdened with stories or fear of things going wrong.  This gives them a real advantage over us.  As she drew closer to birthing, Ella slowed down, didn’t want to go out for walks and became much more introverted, perhaps even introspective.

Preparing for birth

I had a large whelping box made for her and put it in a room where she could go and be undisturbed when the time came.  I put her favourite bed in there and her food and water bowls, so she knew this was her place.  The curtains were pulled, windows closed and the room was nicely quiet and dim.  I think she was bemused by the change in her accommodation but happily went in there for her meals, but would only use the water bowl she and our other dog shared, that was in the usual place.

Birth behaviour

I was fully expecting her to disappear into the room when she went into labour and to then find her and her pups ensconced in the box sometime later.  She however decided not to do the isolation thing and instead sought me out.  She followed me around the house as I got on with the jobs I needed to do.  It only dawned on me then that she did not want to do this alone.  This I guess was not so surprising as she was very bonded to me, we ran together each morning, she slept at the foot of my bed and she came to work with me each day I was visiting clients.  She was midwifery dog!

Individualised needs

So, I took her to her birthing room and we settled down together, needless to say she didn’t want to get in the box and proceeded to birth her pups on towels all round the room.  It was amazing to see her work with her labour and move around constantly, again this didn’t meet my expectations which were that she would lie down and stay there until the last pup was born.  She wriggled her body, stood up, lay down, stood up again and wandered around for the whole of the birth.  She panted and whined and looked to me for reassurance.  Unsure of what else I could do, she seemed to be soothed by my low calm voice and me stroking her head.

Expectations of birth

Whilst I thought I was being very supportive of physiological birth I was also being quite rigid in my thinking and expecting her to behave in a certain way.  I realised that I had not thought about her individual needs and assumed hers would be the same as every other dog.  I had seen videos of dogs whelping but hadn’t processed that of course not all dogs would be the same.

What women need

In my life as a midwife, I have been guilty of assuming I knew what women want and need, again still from the perspective of supporting physiological birth, but this type of thinking does not serve women.  In general, based on what women have told us from across the world, during labour women need to have a sense of privacy and safety, they need to be able to disengage from logical thinking and not be distracted.  They need to be warm and not feel hungry and they want to know and trust the midwife who is with them.  All these factors tell the brain that they are safe and that the anti-stress response can be activated.

Birth and a sense of safety

Mammals birth when they feel safe and are in the anti-stress state, releasing oxytocin.  Oxytocin is an everyday hormone that is released to support normal wellbeing.  It enables us to feel relaxed and happy, on a mental and physical level, and be in a state of normal functioning.  Oxytocin is also the main hormone for labour and creates the contractions needed to birth a baby.  If we think about other situations in which women release oxytocin, such as sleep, it helps us to imagine what the birth environment needs to look like.  Like birth, being able to sleep requires people to feel safe, unstressed and unthreatened.  Most people would need sleep to occur in a private, safe environment, where they can relax.  They may want the room to be quiet, dark, warm and restful.  The birth environment should reflect these needs.

Supporting oxytocin release

If creating a place that is safe, quiet and calming is your starting point then it means women have the environment that supports the release of oxytocin.  However, what makes individual women feel safe and secure will differ widely and they may want to modify their surroundings.  For some it is absolutely necessary for them to be in a quiet darkened room where privacy is sacrosanct, but I do vividly recall one client who wanted the curtains and windows wide open and music playing loudly as she laboured.  She had invited many people to be there for the birth and she seemed to relax deeper into her labour as more people arrived.  By the time she birthed her baby there were 11 people in the room, but the important factor was that they were all there at her request.

Not being prescriptive

Whilst I would not tell women they should have lots of people present at their birth, having them there clearly worked for this client.  As midwives, we need to be flexible in our thinking and accepting of women’s wishes.  We also need to be able to adapt to women’s changing requirements.  I remember another client who decided, in the throes of labour, she didn’t want anyone in the room when she birthed, not even her husband.  We asked if it was ok to be out of sight in the adjoining corridor and she was happy with that.  So, we sat there quietly and waited until we heard the cries of the baby and the woman telling us we could come back in.  She didn’t need us.  She knew that everything she needed to birth her baby safely and effectively was within her, and we were a hindrance, distracting and preventing her from birthing.

Learning from being with women

This was very interesting to me because generally I sit quietly and unobtrusively when women are in labour and didn’t think I would be affecting them in any way.  I only do tasks, such as taking a pulse or blood pressure, as we have agreed on prior to labour, but even this was too much for this woman, on her birthing day.  My mere presence was interference and I needed to accept this, even if I couldn’t see how I was interfering, and think about how else I could support her.  What makes women feel safe, rather than what you think makes them feel safe, is key.  For some women, having someone watching them constantly, anticipating something going wrong, is not going to inspire confidence or a sense of calm and is instead fear-inducing.  This is exactly the wrong state for safe birth.  When women are fearful or stressed they stop releasing oxytocin and start releasing stress hormones and this can cause labour to stall, or stop altogether, and leads to birth interventions.

Life-long learning

So, I learned to listen and respect what women told me.  Women know what they need, they feel it.  We birthed for millions of years very effectively without medical interventions, we survived and thrived as a species because women knew what to do to perpetuate our existence.  They still do!  In an environment that best suits the individual woman, the vast majority of women birth well. For those women who encounter complications there are obstetric services that are very skilled in helping to resolve the problem, but they should be used judiciously.

Top tips for birth

Identify which environment will help you feel safe and secure

Identify which people will help you feel safe and secure 

Learn when and how your body releases oxytocin

Inform yourself about how your body works during birth

Be active in labour to help your baby move down through your body

Be in control of your birth and make informed decisions

Our birth preparation courses are designed to give you all the information you need to prepare for a positive birth.

Parenting choices

Whether to give vitamin K to their baby is often the first decision parents will need to make following the birth and this usually happens within the first hour.  It is generally assumed that parents will agree to giving it, and that discussion only needs to take place about how the baby will receive the vitamin K.  The choices for this are, orally where drops are given into the baby’s mouth or intramuscular injection.  From talking to parents my understanding is that the topic is rarely discussed fully and that their knowledge of the issues even after the discussion is quite limited.

Informed Consent

How is it that we, as health professionals, understand the legal principle that those people with parental rights need to provide informed consent for interventions involving their children, but then in certain circumstances overlook that right?  The belief that healthcare professionals know best, and can tell people which choices to make, is outdated and not supported in law.

So, why is there little discussion about vitamin K?  It is certainly not a straightforward issue, but that is no reason not to talk about it and to ensure parents understand the issues so that they can make informed decisions.  Whilst healthcare professionals and policy makers develop standardised care pathways that address issues on a population basis, resulting in the recommendation to give vitamin K to all babies, parents still have the right to make individualised choices for their babies.

Prophylaxis

The vitamin K given routinely after birth is a form of prophylaxis.  This means it is given as a preventative measure rather than as a treatment for a condition the baby has developed.  It is offered because all babies are born with lower levels of vitamin K, compared to older children and adults, and it is one important component in a complex system that prevents bleeding.

Why do all babies have lower levels of vitamin K?  The answer is we don’t know, but the medical assumption is that the relative low level means there is a deficiency which needs correcting.  Vitamin K is offered to all newborn babies with the aim of preventing a bleeding disorder from developing in a small number of babies who cannot be identified before the condition becomes apparent.  So, thousands of babies need to be treated in order to protect one baby who would otherwise become affected.

Vitamin K deficiency bleeding

The bleeding disorder is called vitamin K deficiency bleeding (VKDB) and happens in three different timeframes:

Early-onset – the disorder develops within the first 24 hours of life and is almost entirely associated with specific drugs prescribed to mothers, including anticoagulants, anticonvulsants and certain antibiotics.  This form of the disorder is not prevented by giving vitamin K prophylactically.

Classic-onset – the disorder develops between 2 and 7 days after birth.  Bleeding can occur in the gut, the nose or from any wounds.  Prophylaxis does very significantly reduce the incidence of VKDB but may not eradicate it entirely.

Late-onset – the disorder develops between 8 days and 4 months of age.  It can happen if the baby is not able to build up reserves of vitamin K through feeding, production in the gut or storage in the liver.  Late-onset VKDB presents the most serious danger and is the form that risk analysis focuses on.  Bleeding can occur in the brain, gut or skin, and can result in severe illness and, in very rare cases, death.  Prophylaxis does significantly reduce the incidence of late-onset VKDB, however, late bleeding is often found to be secondary to liver disease and in these cases it may not prevented by prophylaxis.

Incidence of late-onset VKDB

The incidence of late-onset VKDB in untreated babies is approximately 1:11,000, although some resources (US Centers for Disease Control and Prevention) quote a much rarer incidence of 1:25,000.  Most babies who develop late-onset VKDB will recover fully with prompt treatment.  A small study (McNinch et al. 2007) has shown that 1% of those babies who developed late-onset VKDB died, so whilst the chance is small, the consequences can be serious.

The group of babies most affected these days are those who are breastfed, and not given prophylactic vitamin K.  Because formula milk is supplemented with very high levels of vitamin K babies fed this way have reduced incidence of VKDB.  Although you may hear that breastmilk is deficient in vitamin K this is not true, breastmilk contains physiological levels of vitamin K and babies with a healthy gut microbiome, helped by breastfeeding, will start to produce their own vitamin K a few days after birth.  Whilst this process has evolved and works for the vast majority of babies, there is, for a very small number of babies (1:11,000), an issue, often unidentified, that leads to the bleeding disorder.

Risk factors for late-onset VKDB

Can babies who are likely to develop late-onset VKDB be identified before anything happens?  Certain conditions are likely to increase the possibility and babies who have liver disease are known to be more prone to develop VKDB, but liver dysfunction is often not diagnosed straight away after birth and so these babies can be missed.  Babies with diarrhoea, coeliac disease and cystic fibrosis also have a greater chance of having VKDB, because they have difficulty in absorbing vitamins, but again these conditions may not be picked up immediately and their increased risk may not be identified.

We know that other babies, without significant medical conditions, can develop VKDB but it is difficult to predict which babies this may happen to.  It makes sense that if babies need to receive vitamin K from their food, then any baby who does not feed well may be more likely to develop VKDB.  These babies may then have a delay in the establishment of their gut microbiome, resulting in a lag in the production of vitamin K, which could compound the probability of the disorder occurring.

Should vitamin K be given automatically?

So, if there is a risk to babies of developing VKDB and there is a very effective form of prophylaxis, why do we need to talk about this at all?  Is it not a no-brainer?  Just give it!  This, I think, is the perspective that many healthcare professionals come from, but it does not allow parents to fully understand the issue or explore the uncertainties that exist and assess the risk in their personal context.

There are several questions that remain unanswered in relation to vitamin K.  For example, could there be some physiological advantage to babies of having lower vitamin K levels that we are unaware of?  Could giving babies much higher doses of vitamin K than are physiological be harmful in the short or long-term?  We do not know the answers because the research has not been done and is unlikely to do be done.  These issues do need studying though, so that we can avoid unintended consequences of vitamin K prophylaxis.

Are there any disadvantages to giving vitamin K?

Should we consider whether there are any drawbacks to giving vitamin K or just accept that if it does more good than harm then that is enough?  Any drug can cause problems, from the drug itself to the substances that it is carried in, so does this need consideration from parents?  What are the possible detrimental effects of an injection?  Does the potential for pain, distress, local infection, nerve damage, bleeding or bruising have any bearing on the decision?

Could the possibility for oral vitamin K preparation to disrupt the gut microbiome and the priming of the baby’s immune system be worthy of a discussion so that parents can try to balance the risks?  Does the chance that the baby spits out some of the oral preparation, making it uncertain whether the baby has received an adequate dose, mean that parents are encouraged to view the injection as the only viable option?

Some vitamin K preparations are made using animal products and are therefore not suitable for vegetarians, vegans or others with related dietary requirements and this is not always discussed.  However, if parents are aware of this and still want to give vitamin K, they can ask to have an alternative preparation that does not contain animal products, and which meets their individual needs.

What are the alternatives?

If parents are unsure of giving vitamin K are there any alternative approaches they can take?  If they are concerned about disrupting the gut microbiome and the priming of the baby’s immune system, but want to avoid the injection, they could choose to delay giving oral vitamin K until the baby has started feeding effectively and the gut microbiome has been seeded.

Alternatively, is watchful waiting a reasonable option?  If parents choose to wait watchfully then they need to be aware of how well their baby is feeding, as poor feeding can predispose the baby to VKDB, and to watch out for signs and symptoms of the disorder, which include bleeding, bruising, poor feeding, sleepiness, skin or gums that are paler than before and yellowness in the white part of the eyes after 3 weeks of age.

Parents using this approach also need to know that there are not always early signs and bleeding could occur without warning.  In this case prompt action and treatment would be needed.  Instead of giving the baby vitamin K, some people take measures to increase the vitamin K levels in their breastmilk and there is evidence that dietary supplements are effective in increasing amounts enough to provide adequate levels of protection to the baby.  Currently the evidence suggests that just increasing dietary sources of vitamin K is not enough to raise levels in breastmilk to fully protect the baby from VKDB.

Making informed decisions for your baby

Making decisions for yourself or your baby can seem daunting.  Decision-making is very personal and will involve your beliefs, experiences and perceptions of risk.  It is vital to have the information you need to be able to weigh up the pros and cons of any intervention and factor in your individual circumstances.  An open discussion with your healthcare provider should help you do this and then you can make the decision that is right for you and your baby.